Wound preparation is the single most important step in treating
a traumatic wound. Proper ED wound management can help restore integrity and
function of injured tissue, minimize the risk of infection, and
assure the best possible cosmetic result. The majority (80% to
90%) of wounds treated in EDs heal with a good outcome.
However, careful preparation is particularly important when underlying
medical conditions affecting wound healing are present (Table 44-1). Many traditional methods of wound preparation
have surprisingly little scientific validation.1,2 This
chapter reviews the basic principles of wound preparation, using available
experimental models and prospective clinical studies, where available,
to justify these techniques.3
Table 44-1 Risk Factors
for Poor Wound Repair Outcome
| Save Table
Table 44-1 Risk Factors
for Poor Wound Repair Outcome
|Chronic renal failure|
|Peripheral vascular disease|
|Poor wound healing|
|Connective tissue disorders|
Although adoption of aseptic technique represented a major advance
in medical care, the extent required for ED wound repair remains
unclear. Full sterile technique, with the physician wearing hair
cap and face mask in addition to sterile gloves, does not reduce
the incidence of postrepair infections.4,5 The
benefits of hand antisepsis prior to wound repair in the ED is unproven.6 Clean,
nonsterile gloves have similar postrepair infection rates when compared
to sterile gloves.7–9 These findings suggest
that aspects of the sterile technique may be curbed, leading to
time and cost savings per laceration by using common-sense cleanliness.
In general, pain control should be provided before extensive
wound preparation. Not only is this more humane, the administration
of anesthesia and analgesia will enable better preparation and treatment
if patients are relaxed and able to cooperate without undue anxiety
and pain. Prior to the administration of local or regional anesthetic,
the sensory, motor, and vascular examination should be performed
at, and distal to, the wound site.
Sensory examination should include evaluation of pain, temperature, touch,
pressure, and/or position. Motor examination should assess movement
and strength of tendons and muscles around the wound site as well
as muscles that are innervated by nerves traversing the site. Vascular
examination should assess distal perfusion by noting skin color, temperature,
capillary refill time, and quality of pulses. Two additional assessments
may be required before local or regional anesthesia: (1) testing
of two-point discrimination on the volar pads of the thumb and fingers
and (2) comparison of the systolic blood pressure in the injured extremity
with the noninjured one. Two-point discrimination (<6 mm) checks
for possible injury to the digital nerve. Systolic blood pressure comparison
(using a Doppler stethoscope and pneumatic cuff) assesses for hemodynamically
significant arterial obstruction.
Control of bleeding is necessary for proper evaluation of a wound.
Diffuse bleeding most often occurs from the subdermal plexus and
superficial veins. Direct pressure with saline-soaked sponges or
gauze is usually effective in stopping this type of bleeding.
Bleeding from a minor exposed lacerated vessel of the
extremities is best controlled by direct pressure applied
with a gloved fingertip directly on the vessel. Once bleeding from
a minor extremity vessel is halted, more permanent control can be
achieved by clamping the involved vessel, isolating a short length,
and ligating it with absorbable synthetic suture (typically 5-0).
Major arteries of an extremity should not be ligated, and surgical
consultation is needed for further hemorrhage control if this type
of bleeding is present. Exercise caution clamping vessels in facial wounds
to avoid damaging facial nerves. Scalp lacerations can bleed extensively
from the wound edges due to the highly vascular subcutaneous layer.
Scalp bleeding can be controlled by the use of specially designed clips
applied along the wound edges (Figure 44-1).
Raney clips used to control bleeding from the wound edges
of scalp lacerations. A. Applicator used to apply open
clip. When the applicator is released, the clip closes and pinches
on the wound edges. B. End and front view of open clip. C. End
and front view of closed clip. (Courtesy of J. Stephan Stapczynski,
For bleeding wounds where the involved vessel is not visible,
a figure-of-eight or horizontal mattress suture (Figure
44-2) applied adjacent to the wound edge near the site of bleeding
will sometimes achieve control. However, this technique may impair
blood flow and leave nonviable tissue in the wound.
A. Standard horizontal mattress suture. B. Figure-of-eight
suture. (Reproduced with permission from Roberts JR, Hedges JR: Clinical
Procedures in Emergency Medicine, 4th ed. Copyright © 2004. Saunders,
An Imprint of Elsevier.)
Chemical means of hemostasis is typically done using epinephrine
mixed with local anesthetics in concentrations of 1:100,000 or 1:200,000
and injected into the wound area. This will induce local vasoconstriction
that will allow a longer duration of anesthesia and a larger total
local anesthetic dose due to the depot effect of the vasoconstriction.
The use of epinephrine mixed with local anesthetics is safe for
digital nerve blocks and in procedures on the nose and ears in patients without
small vessel disease.10,11 While epinephrine interferes
with wound healing in experimental animal models,3 no
increase in wound infection has been observed with the addition
of epinephrine to local anesthetics used in the ED.
Physical means of applying pressure to bleeding include the use
of gelatin, cellulose, or collagen sponges placed directly into
the wound. Denatured gelatin [Gelfoam® (Pfizer,
Inc., New York, NY)] has no intrinsic hemostatic properties
and works by the pressure it exerts as it becomes a ...