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
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
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).
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
43-1 Pertinent Medical History
| Save Table
43-1 Pertinent Medical History
|Pain, swelling, paresthesias, muscle weakness|
|Type of force causing injury|
|Crush (blunt) or shear (sharp)|
|Bite or puncture|
|Elements of contamination|
|Time elapsed from injury until initial cleansing |
|Time elapsed from injury until presentation|
|Wound care performed prior to ED arrival|
|Object that caused injury (glass, wood, etc.)|
|Cleanliness of body and environment at time
of injury and afterward|
|Factors resulting in injury|
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