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Approximately 8 million traumatic wounds are evaluated in EDs across the U.S. annually, accounting for about 7% to 8 % of all ED visits.1,2 The face, scalp, fingers, and hands are the most commonly involved areas of injury.3 Approximately 40% of traumatic lacerations seen in the ED are caused by blunt objects.3 Wounds on children differ from wounds on adults; lacerations in children are more likely to be located on the head and be linear, shorter, less contaminated, and more often caused by blunt trauma.4,5

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Evaluation of the patient with a traumatic wound begins with overall patient assessment. Less obvious but more serious life-threatening injuries need care before directing attention to wound management. Determine the patient’s past medical history and circumstances surrounding the injury.6 Remove rings or other jewelry that encircle the injured body part as soon as possible so they do not act as constricting bands when swelling progresses. Remove clothing over the injured area to reduce the potential for contamination.

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External bleeding can usually be controlled by direct pressure over the bleeding site. When possible, replace skin flaps to their original position before applying pressure in order to avoid exacerbating vascular compromise. Tourniquet application is rarely needed. Two exceptions are when an arterial tourniquet is necessary to stop life-threatening exsanguination or when a tourniquet is needed for a short period to create a “bloodless” field for wound inspection. Amputated fingers or extremities should be covered with a moist, sterile, protective dressing, placed in a waterproof bag, and then placed in a container of ice water for preservation and consideration for future reattachment. Before wound exploration, cleansing, and repair, most patients will need some form of anesthesia.6,7 Systemic analgesia or procedural sedation may be required (see Chapter 38, Acute Pain Management in Adults, and Chapter 41, Procedural Sedation and Analgesia).

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History and Comorbidities

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Proper wound management begins with a pertinent patient history (Table 43-1). A variety of patient factors have adverse effects on wound healing and increase the rate of wound infection—extremes of age, diabetes mellitus, chronic renal failure, obesity, malnutrition, the use of immunosuppressive medications, the presence of connective tissue disorders such as Ehlers-Danlos syndrome, Marfan syndrome, osteogenesis imperfecta, and protein and vitamin C deficiencies.6 The most predictive factors for infection are the wound characteristics of location, age, depth, configuration, and contamination.8,9

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Table Graphic Jump Location
Table 43-1 Pertinent Medical History 

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