PRINCIPLES OF INITIAL EVALUATION
Evaluation of the patient with a traumatic wound begins with overall patient assessment.1,2 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.1,2 Remove rings or other circumferential jewelry 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.
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 may be necessary to stop life-threatening exsanguination or when needed for a short period to create a "bloodless" field for wound inspection.3,4,5 Amputated fingers or extremities should be wrapped 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 Systemic analgesia or procedural sedation may be required (see chapter 35, Acute Pain Management, and chapter 37, Procedural Sedation).
Proper wound management begins with a pertinent patient history (Table 39-1).1,2 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, and protein and vitamin C deficiencies.1 Predictive factors for infection are the wound characteristics of location, age, depth, configuration, and contamination.7,8
TABLE 39-1Pertinent Medical History |Favorite Table|Download (.pdf) TABLE 39-1 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
Intentional or unintentional
Occupation or nonoccupation related
Assault or self-inflicted
Foreign body potential
Did the object break or shatter?
Foreign body sensation
Removal of portion of object
Occupation and handedness
Anesthetics, analgesics, antibiotics, and latex
Chronic medical conditions that increase risk of infection
Chronic medical conditions that increase likelihood of poor wound healing
Previous scar formation (hypertrophic scars or keloids)
Ascertain the tendency of patients to form hypertrophic scars or keloids by both history and examination, as past experience may predict poor scar formation. Black and Asian patients are more prone to keloid ...