emergency wound management

Wound care

wound irrigation - current recommendation is to irrigate the wound with a high velocity "jet" by taking a 35 cc syringe and a 19 guage needle and squirting the wound with 200 mls or more of normal saline; peroxide is not recommended for the main part of the wound although it may be of value to cleanse the wound edges of dried blood and detritus. Peroxide may interfere with the tissue viability

abrasions require vigorous scrubbing under local anesthesia if necessary, with soap or betadine and a brush. Anesthesia is topical.

a wound must be explored for deep tissue injuries such as tendons and nerves

deferred wound closure in

wounds over 6 hours in age especially if dirty; longer if facial
wounds contaminated by saliva such as bites especially human which easily get infected with Eikenella species
wounds over fractures
when there is a foreign body which cannot be removed
wounds in uncooperative patients

dangerous wound scenarios

high velocity missiles usually have blast effect which is remote tissue destruction difficult to ascertain immediately.
human bites are prone to infection and can occur on the knuckles due to a punch to the mouth, if the history is inaccurate and an unrecognized human bite is not copiously irrigated, covered with antibiotics and left open, a serious deep tissue infection often ensues.
injuries due to glass or other brittle substances often harbor foreign bodies which have to be identified by xray or ct scan or fluoroscopy or xerogram and removed in almost all cases.
stab wounds often seem innocuous but must be presumed to be deep and injurious to deep tissue structures until proven otherwise.
animal bites can often be closed and observed closey with coverage by broad spectrum antibiotics.
all wounds must be evaluated in terms of mechanism of injury as well as sufficient physical exam and history since during the violence another injury may have also occurred which is masked by the attention paged to the apparent wounds. For example a child developed slipped capital epiphysis after being worked up for head injury due to being beaten up. A review of the chart did not disclose an exam of the hips on this patient at the time of the injury.
wounds to the thorax and abdominal wall may be coexstensive with a pneumothorax or a peritoneal perforation. Thoracic wounds should not be probed but xrays taken. Abdominal wounds often have to be explored to demonstrate peritoneal integrity.
injuries to the anatomic compartments of the extremities may lead to compartment syndrome and functional impairment.
all dirty wounds must be thoroughly irrigated and covered with antibiotics and tetanus prophylaxis is a consideration in all wounds.
puncture wounds through sneakers can lead to pseudomonas osteomyelitis and consideration must be given to wound irrigation and proper antibiotic prophylaxis.
wounds occurring in lake or sea water have certain epidemiological considerations attached to them and proper antibiotic coverage must be ascertained.

go to