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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

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 ...

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