Key Practice Points
To prevent unexpected syncope and to provide for patient comfort during wound care, the patient is placed in the supine position. Parents or friends, who want to stay with the patient, are at risk as well.
Most bleeding can be stopped with simple pressure. Blind instrument clamping is avoided.
All rings and jewelry are removed from the wound area to prevent ischemia as a result of swelling.
All wounds are contaminated with bacteria and should be cleansed and irrigated early after arrival if care is to be delayed beyond 1 to 3 hours.
Severe soft tissue injury is an emergency and requires rapid and aggressive care.
Small, innocuous wounds can be caused by more serious problems such as cardiac arrythmias.
Patient Comfort and Safety
If there is the slightest question about a patient’s ability to cope with his or her injury, the patient is placed in a supine position on a stretcher. Loss of blood, deformity, and pain are sufficient to provoke vasovagal syncope (fainting), which can cause further injury from an unexpected fall during evaluation or treatment. The attire of the caregiver should be consistent with universal precautions. Because wound care can be strenuous, the caregiver should be comfortable and relaxed before proceeding. Sitting, when possible, is recommended.
Relatives or friends accompanying the patient also can respond in a similar manner. As a rule, relatives and friends are encouraged to sit in the waiting area unless the physician or nurse determines that staying with the patient would be beneficial (e.g., to comfort an injured child). The parent or friend should be asked if he or she feels comfortable with that arrangement.
Most bleeding can be stopped with simple pressure and compression dressings. There is no need for dramatic clamping of bleeders. Clamping is reserved for the actual exploration and repair of the wound under controlled, well-lighted conditions. Blind application of hemostats in an actively bleeding wound can lead to the crushing of normal nerves, tendons, or other important structures.
Rings and other jewelry must be removed from injured hands or fingers as quickly as possible. Swelling of the hand or finger can progress rapidly after wounding, causing rings to act as constricting bands. A finger can become ischemic, and the outcome can be disastrous. Most items of jewelry can be removed with soap or lubricating jelly. Occasionally, ring cutters have to be used ( Fig. 2-1 ). The sentimental value of a wedding ring should never be allowed to impede good medical judgment. A jeweler always can restore a ring that has been cut or damaged during removal. Another technique for removing rings (steel, titanium) that cannot be cut is described in Chapter 13 .
Pain relief begins with gentle, empathic, and professional handling of the patient. Occasionally, it is necessary to administer pain-reducing or sedative medications to patients being treated in the emergency wound care setting. Sedation and specific pain relief measures are discussed more completely in Chapter 6 .
Wound Care Delay
If there is going to be a delay from initial wound evaluation to repair, the wound is covered with a saline-moistened dressing to prevent drying. The dressing need not be soaked and dripping wet. Delays that extend beyond 1 hour require that the wound be thoroughly cleansed and irrigated before the saline dressing is applied. If extended delays are inevitable, antibiotics occasionally are considered to suppress bacterial growth. If antibiotics are administered, they should be given early to provide the maximal protective benefit. Chapter 9 discusses further recommendations for the early administration of antibiotics.
Children with Lacerations
Particular care must be taken with children who have wounds and lacerations. The pain and fear generated by the experience can be reduced significantly by a few simple measures. The child should be allowed to remain in the parent’s lap for as long as possible before wound repair. Most of the physical examination can be performed at that time. If hemostasis is required, and if the parent is willing to cooperate, he or she can be allowed to tamponade small, bleeding wounds. Parents also can apply topical anesthetics. Careful judgment has to be used when handling children and their parents. It is common for some parents to be unable to tolerate the sight of their child in pain, and they often do better in the waiting room while care is being delivered. It is remarkable how some children stop crying when the parent has left the treatment area. Pediatric considerations in wound care are discussed in detail in Chapter 5 .
Severe Soft Tissue Injuries
Providers of emergency wound care occasionally are confronted with patients who have severe, but not life-threatening, soft tissue injuries, usually of the distal upper or lower extremities. Power tools, industrial machines, farm implements, and mowers commonly cause these injuries. Patients often present with extensive skin lacerations, combined with varying degrees of nerve, tendon, or vascular involvement. On the patient’s arrival at the emergency department, several steps, outlined here, are performed to ensure the stability and comfort of the patient and to evaluate and protect the injured limb. These injuries may include an amputated part; guidelines for the management of that part are described in Chapter 13 .
ABCs (airway, breathing, circulation): Because of the severity of these injuries, the airway and vital signs are assessed to ensure the stability of the patient. A brief history and general system survey are carried out to rule out any secondary injuries or modifying conditions.
Hemorrhage: Any bleeding, as described earlier, is controlled by direct pressure. Tourniquets are indicated only for severe bleeding of an extremity that cannot be controlled by direct pressure, which is a rare occurrence. Should a tourniquet be necessary, proper technique must be observed. Edlich etal. recommend that “after elevating the injured extremity for 1 minute, the blood pressure cuff is inflated to the lowest pressure that will arrest the bleeding. This measured level of inflation can be maintained for at least 2 hours without injury to the underlying vessels and nerves.”
Pain relief: The most effective pain relief for severe hand or foot injuries is nerve blockade with local anesthetics. Nerve blocks are performed only after sensory and motor function is evaluated and documented (see Chapter 6 for nerve block techniques). Pain relief for adults also can be accomplished with parenteral (intravenous or intramuscular) medications, meperidine (Demerol), 25 to 50 mg, or morphine, 2 to 5 mg. These medications can be supplemented with promethazine (Phenergan), 12 to 25 mg to reduce the possibility of vomiting. See Chapter 5 for pain relief in children.
Tetanus immunization: Because patients with severe soft tissue wounds are more likely to be at risk for tetanus, tetanus immunization status has to be determined. See Chapter 21 for immunization recommendations.
Antibiotic prophylaxis: Because of the severe nature of these wounds, they are susceptible to infection. The most common organisms cultured from these wounds are Staphylococcus aureus and β-hemolytic streptococci. Coliforms and anaerobes are cultured in smaller numbers. The most feared organisms are the soil-borne Clostridium species, but these rarely cause infection. Wounds caused by tools and industrial machines are predominantly contaminated with gram-positive organisms. Farm implements and gardening tools that come in contact with soil have a higher proportion of coliforms. These differences have implications in the selection of antibiotics. For clean, non–soil-laden wounds, a first-generation cephalosporin provides adequate coverage. In patients with severe allergies to penicillin or cephalosporins, vancomycin can be given. In soil-laden wounds, the addition of an aminoglycoside provides good coverage. It cannot be overemphasized that antibiotics are no substitute for aggressive wound cleansing, irrigation, and débridement.
Wound evaluation: A functional examination is performed and documented. Loss of pulse or circulation is a serious finding and requires emergent intervention. Sensory and motor function is evaluated and documented. Tendon function is tested by individual or group action when possible. All severe soft tissue wounds are radiographed to assess bone integrity and the presence of foreign bodies.
Wound management: For the most part, little can be done for these wounds in the emergency department. Loose, gross contaminants can be removed. After evaluation, the wound is covered with sterile gauze pads and a wrap is moistened with sterile saline. Appropriate splints are applied as indicated.
Consultation: These wounds require definitive care by consultants with expertise in managing severe extremity and soft tissue injuries. Most commonly, plastic or hand specialists are consulted early after the arrival of the patient. The operating team is notified early as well to prepare for the definitive care of the patient in the operative room.