The common methods of wound care are reasonably effective, resulting in a good outcome for the vast majority of cutaneous wounds treated in the ED.1,2,3 Wound preparation is the most important step in restoring tissue integrity and function, minimizing infection risk, and achieving the best possible cosmetic result. However, there is surprisingly little scientific validation for most of these methods.4,5,6,7 With some patient and wound characteristics (Table 40-1), the risk of improper healing increases, and the importance of careful wound preparation becomes more important.4,5,8,9,10
TABLE 40-1Risk Factors for Poor Wound Repair Outcome |Favorite Table|Download (.pdf) TABLE 40-1 Risk Factors for Poor Wound Repair Outcome
|Patient Factors ||Wound Factors |
Immunosuppression: diabetes, chemotherapeutic agents, chronic steroid therapy, chronic renal failure, hematologic malignancies, congenital immunodeficiencies
Tissue ischemia: peripheral vascular disease, anemia, vasculitis
Poor wound healing: elderly, cigarette smoking, malnourished, connective tissue disorders
Thorough cleansing and meticulous wound evaluation and repair can be painful procedures, so adequate anesthesia is important for patient comfort and cooperation. Choice of anesthetic agent and route varies according to wound location and size (see chapter 36, Local and Regional Anesthesia). The sensory, motor, and vascular examination should be performed at and distal to the wound site prior to the administration of local or regional anesthetic.
Sensory examination should include evaluation of pain or touch. If a wound involves the hand or fingers, additional assessment for digital nerve injury using two-point discrimination (normal <6 mm) on the volar pads should be performed prior to local or regional anesthesia administration. 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. Comparison of the systolic blood pressure in the injured extremity with the noninjured one (using a Doppler stethoscope and pneumatic cuff) assesses for hemodynamically significant arterial compromise. While performing the sensory examination prior to the administration of an anesthetic is important, adequate motor examination can be occasionally limited by pain, with improved strength testing following achievement of pain control.
Wound irrigation is widely considered to be the most important step in the management of acute wounds; it decreases bacterial count and helps to remove debris and foreign bodies, thereby reducing the risk of wound infection.1,3,11 Choices in the performance of wound irrigation include solution composition, temperature of the irrigant, pressure with which it is applied, and the total volume used.