(erika)EM Exam 1: Key Terms on Wound Management & Emergencies

when assessing a patient with a laceration, what components of a history do we need to collect?

- time of injury

- location of injury

- MOI

- degree of contamination

- PMH, meds, allergies

- tetanus immunization status

- occupation and handedness

laceration with paresthesia is associated w/ what?

laceration with loss of function is associated w/ what?

nerve injury

tendon injury

what are factors that can affect wound healing?

- pt age

- location of injury

- MOI

- meds

- PMH

- presence of foreign body

- previous keloid or scar formation

what factors can help us predict the risk for infection assoc/w a laceration

- time since injury

- MOI (crush vs lac)

- location of injury

- degree of contamination

which location of the body is infection of a wound more likely to occur?

less likely to occur?

extremities and moist areas

face and scalp

what are the four key aspects of a physical exam when assessing a laceration on a patient?

- location and damage to underlying structures

- presence of devitalized tissue

- contamination and/or presence of FB

- complete neuro exam (gross motor, sensory, vascular)

T/F: imaging is often needed for most lacerations

false; imaging is not needed for most lacerations

1 multiple choice option

in what scenarios would it be appropriate to obtain imaging of a laceration?

- eval for FB

- eval for underlying fx

- bite wounds

which imaging modality can obtain most FBs

plain XR

this is an essential component to wound preparation and involves removing bacteria and other particles to reduce infection risk

wound irrigation

what can be given before wound irrigation to promote better tolerance from the patient?

wound anesthesia

T/F: wound soaking is not effective

true

1 multiple choice option

what solution(s) should be used to irrigate a wound?

tap water, sterile water, or normal saline solution

how much solution should be used to irrigate a wound?

50-100 mL per cm wound length

low pressure wound irrigation is used for what types of wounds?

high pressure irrigation?

simple, uncontaminated wounds (face, scalp)

contaminated wounds

what equipment is needed to perform irrigation of a wound?

- 18G angiocath or irrigation shield

- 20-50 mL syringe

- sterile saline or tap water

- gloves

- face shield

what exam needs to be performed prior to administration of anesthesia?

neurovascular exam

what trio of anesthetics are used topically for wound care?

LET - lidocaine, epi, tetracaine

which injected anesthetic is most commonly used?

which prolongs the duration of use by 25-50%?

which provides a longer duration of 1.5-3hrs?

lidocaine

lido + epi

bupivacaine

what is the major problem assoc/w all local anesthetics?

systemic absorption, can lead to CV and CNS toxicity

when injecting local anesthesia near a wound, what needs to be done prior to injection to avoid inadvertent injection into vasculature?

aspiration

this type of anesthetic is used around peripheral nerves; it does not distort the wound, it offers better pain control, but it does require more time

nerve blocks

what is the most common nerve block?

digital nerve block

what are signs of tissue necrosis?

- gray or black in color

- lack of bleeding when tissue incised

T/F: hair removal during wound debridement can help decrease the risk of infection

false; hair removal has no effect on infections, and shaving may increase infection risk

1 multiple choice option

identify the wound closure approach:

- closed in acute phase on presentation

- optimal time not defined (<12 hrs old)

- low risk: infection, retained FB, NV compromise, damage to underlying structures

primary closure

identify the wound closure approach:

- high risk of infection

- wound irrigated, cleaned, debrided, bandaged

- repair in 4-6 days

delayed primary closure

identify the wound closure approach:

- wounds presenting very late after injury

- heals spontaneously and slowly

- larger scar

secondary intention

what are the indications for using adhesive tape (steristrips) to close a wound? (3)

- linear and low tension

- superficial

- thin skin that may not hold sutures (skin tears)

what are the contraindications to using steristrips for wound closure? (3)

- high tension wounds (i.e. over joints, gaping wounds)

- wounds that require layered closure

- wounds in high-moisture areas

what can be applied to the skin to help improve adhesion of steristrips?

tincture of benzoin

what are the indications for using tissue adhesives ("glues") for wound closure? (3)

- linear and low tension

- superficial

- < 4cm length

what are the contraindications for using tissue adhesives for wound closure? (3)

- high tension wounds

- active infection

- use on mucosal surfaces, skin exposed to bodily fluids, or w/ dense hair

when using Dermabond or Liquiband for closing a wound, what can be added to the closure to provide extra strength?

steri-strips

what are the indications for using staples to close a wound?

contraindications?

scalp lacerations, linear trunk lacerations if cosmesis not priority

gaping wounds w/ layered closure; areas w/ high priority cosmesis

what is the technique for placing staples to close a wound?

- evert wound margins w/ forceps/fingers

- place 1st staple at center of wound using staple gun

- continue bisecting w/ staples until well-approximated

indications for using sutures to close a wound (3)

- clean wounds w/ low risk of infection

- areas of cosmetic concern

- wounds over tendons or nerves

contraindications for using sutures to close a wound (4)

- heavily contaminated wounds

- high risk of infection (i.e. puncture wounds)

- non-cosmetic animal bites

- high risk of tissue destruction (high pressure wounds)

suture type that is used for deep tissue structures or to avoid need for removal

absorbable (gut or vicryl)

suture type that requires removal

nonabsorbable (nylon or prolene)

what needs to be taken into consideration when deciding what type of sutures to use in wound closure?

- cosmetic considerations

- wound tension

which suture types are larger and stronger?

which types are smaller and minimize scarring?

small gauge sizes (3-0, 4-0)

large gauge sizes (5-0, 6-0)

what is the most common type of suture used?

simple interrupted sutures

T/F: most wounds need abx to prevent wound infection

false; most wounds don't need abx; good wound irrigation is sufficient

1 multiple choice option

what is MC bacteria assoc/w animal (dog/cat) bites?

assoc/w human bites?

Pasteurella multocida

Eikenella corrodens

what is the preferred abx for animal and human bites?

augmentin is dogmentin bby

preferred abx for intraoral gaping lacerations?

PCN or amoxicillin

preferred abx for excessive wound contamination (i.e. open/public waters, soil, feces)

abx is based on epidemiology of exposure and pt factors

is it tetanus prone?

wound <6 hrs

no

1 multiple choice option

is it tetanus prone?

wound w/ depth of 2 cm

yes

1 multiple choice option

is it tetanus prone?

wound caused by sharp surface such as knife of glass

no

1 multiple choice option

is it tetanus prone?

wound caused by missile, crush, burn, or frostbite

yes

1 multiple choice option

is it tetanus prone?

infection is present

yes

1 multiple choice option

is it tetanus prone?

wound does not show any signs of devitalized tissue

no

1 multiple choice option

is it tetanus prone?

wound is from a human bite

yes

1 multiple choice option

is it tetanus prone?

wound does not show signs of denervated or ischemic tissue

no

1 multiple choice option

when should a tetanus vaccine be administered following a wound?

what is the incubation period?

ASAP

2-21 days (usually w/in 8 days)

indications for tetanus prophylaxis following a laceration

- incomplete tetanus vax (<3 previous doses)

- 5+ yrs since last vax if tetanus prone

- 10+ yrs since last vax for any open wound

- recovery from tetanus (infection does not confer immunity)

T/F: tetanus vaccination is safe to give in pregnancy

true

1 multiple choice option

contraindication to administering tetanus prophylaxis following laceration

hx of neuro or severe systemic rxn after previous dose

when would TIG (tetanus immune globulin) be given to a patient presenting with a laceration?

if tetanus immunization series is incomplete or uncertain

when educating the patient on care of their laceration, under what circumstances should they return to the office (prior to their scheduled f/u)? (5)

- signs of infection (redness, pain, pus around injury, fever)

- bleeding that will not stop after 10 minutes of direct pressure

- new numbness/tingling around wound or beyond it

- pain at site that is not relieved by taking OTC pain meds

- stitches or staples that come out too soon

what is the protocol when examining an extensor tendon laceration?

- examine extremity/joint in position when injured

- assess tendon extensor function

- close skin, splint in position of function, refer to hand surgeon

what is the protocol for a flexor tendon laceration?

- assess function

- FDS tendon = PIP joint

- FDP tendon = DIP joint

- not repaired in ED

- repair in OR, refer to hand surgeon w/in 24 hrs

punch to the mouth w/ lacerations over MCP joint from teeth

is this sutured?

what abx is given?

clenched fist injury (fight bite)

no d/t infection risk

augmentin

what is the protocol for a fingertip injury where only the skin or pulp is affected?

if there is exposed bone?

conservative tx w/ dressing changes

abx, splint, refer to hand surg

with a subungual hematoma, what percentage of the nail has to be affected to trephinate?

>50%

when would we remove the nail if there was injury to the nail/nailbed?

if avulsion or nailfold disruption

what is the protocol for repairing a nailbed laceration?

repair w/ 6-0 absorbable suture, secure nail in position

when should a soft tissue FB be suspected? (5)

- broken, shattered, splintered objects

- thorns, spikes, branches

- FB sensation

- healed wounds w/ continued sharp pain

- poor wound healing, infection

which foreign bodies are likely to be left in place?

which are likely to be removed?

- small, inert, deeply embedded, asyx

- thorns, wood splinters, vegetative materials, contaminated objects; if neurovascular compromise/infection

where are puncture wounds common?

extremities - plantar foot

when would a puncture wound be considered high risk?

- forefoot

- through athletic shoes

- immunocompromised

what med is given for most puncture wounds if needed?

what med is given for PW through athletic shoes to cover Pseudomonas?

1st gen cephalosporin (cephalexin)

FQ

MC cause of cellulitis when MRSA is not suspected

group A beta-hemolytic strep

tx for cellulitis not caused by MRSA?

tx for cellulitis if MRSA is suspected?

cephalexin, dicloxacillin, clinda

TMP/SMX, clinda, doxy

breakdown of cutaneous barrier leading to localized collections of pus that occur w/in dermis and subcutaneous space

cutaneous abscess

what is the tx of a cutaneous abscess?

when would abx be required?

local incision using scalpel and drainage of purulence

fever, multiple, immunocompromised, large surrounding cellulitis

what are the indications for primary closure of mammalian bites?

- animal (dog if low risk)

- location (face or scalp, esp if gaping wound)

- wound (non-contaminated, simple for single layer closure, no devitalized tissue)

- host (not immunocompromised)

which types of mammalian bites are of high infection risk?

- cat or human bites

- hand or foot wounds

- puncture wounds

what is the initial assessment process for thermal burns?

- stabilize ABCs

- remove clothing and debris

- assess depth and extent of burns

what are the components of a directed history as it pertains to thermal burns?

- burning agent (hot liquids, steam, flame, flash)

- exposure duration (open or closed)

- possible injury (blast, contact w/ electricity, LOC, other trauma)

- if possible, AMPLE hx (allergies, meds, PMH, last meal, events)

what type of burn?

- epidermis only

- no blisters, red

- painful

superficial (first degree)

what type of burn?

- epidermis and superficial dermis

- blisters, moist, red, weeping

- painful to temp, air touch

superficial partial thickness (second degree superficial)

what type of burn?

- epidermis, deep dermis, sweat glands, hair follicles

- blisters, red to cheesy white, wet or waxy dry

- painful to pressure only

- usually requires surgery

deep partial thickness (second degree deep)

what type of burn?

- entire epidermis and dermis

- charred, waxy white, leathery

- no pain

- requires surgery

full thickness (third degree)

what type of burn?

- entire epidermis and dermis

- extends into fascia and/or muscle

- requires surgery

deeper injury (fourth degree)

what is the most common method of categorizing adult thermal burns?

rule of nines

describe the rule of nines

head = 9%

each arm = 9%

torso front = 18%

torso back = 18%

each leg = 18%

for smaller burns, how can we calculate the percentage of BSA involved?

using patient's palm and fingers (1% BSA)

- palm alone = 0.5% BSA

- number of "hands" represents total BSA burned

what is the treatment protocol for minor burns?

- run cool water over burn until skin temp normalizes

- pain control w/ NSAIDs or opioids

- cleanse area w/ soap and water

- apply topical ointment and sterile dressing

- update tetanus if needed

what is the treatment protocol for mod/major burns?

- eval airway and monitor vitals

- labs = ABG, carboxyhemoglobin level, CXR

- est 2 large bore IV lines for fluid resuscitation

- eval and tx traumatic injuries

- address burn wound care

- IV opioid analgesia early, titrate to pain

- update tetanus PRN

- admit to hosp or burn center

in patients with major burns, what is the preferred fluid for fluid resuscitation?

what formula is used to determine the amount of fluids given over the first 24 hrs?

lactated ringers

Parkland formula (adults)

- 4mL x weight (kg) x %BSA burned over initial 24 hrs

- half over first 8 hrs from time of burn

- half in the subsequent 16 hours

for patients with mod/major burns, what is applied to the small burn areas?

what is applied to larger burns?

cool compresses

covered with sterile dry sheets

which burns are treated in the ED?

superficial or localized burns

which burns are transferred to a regional burn center?

- full thickness/third degree burns in any age group

- inhalation injury

- preexisting med disorders that may complicate management

- associated major trauma

- pts who will require special social, emotional, or long-term rehab intervention

most fire-related deaths are from what?

smoke inhalation

what are the physical signs of an inhalation injury?

- facial burns

- singed nasal hairs

- soot in upper airways

- hoarseness, stridor, resp distress

what should be suspected in all pts with smoke inhalation?

how can this be definitively diagnosed?

carbon monoxide exposure

ABG

which subgroup of hymenoptera stings only when provoked but host a subspecies that is more aggressive and will attack in swarms

honeybees and bumblebees