Infection is suggested by pain, warmth, erythema, edema, and purulent drainage. While dehiscence can occur at any time, 7 to 10 days after repair a wound is at its weakest (this also closely coincides with suture removal). Impaired wound healing, primarily from infection, medications (especially corticosteroids), foreign bodies, advanced age, poor nutritional status, diabetes mellitus, and peripheral vascular disease, contributes to dehiscence. Elastic wound closure strips can be applied after suture removal and may reduce dehiscence.
Some degree of scarring is inevitable, but not considered a complication of wound repair. This should be discussed with the patient or caregiver. Wound myiasis is infestation by fly larvae (maggots, see Chapter 21, Tropical Medicine, Myiasis) that invade necrotic tissue.
Management and Disposition
Infections are treated with suture removal, thorough irrigation, and low threshold to explore for missed foreign bodies. A 7-day course of a first-generation cephalosporin or antistaphylococcal penicillin is appropriate; however, if methicillin-resistant Staphylococcus aureus (MRSA) is suspected, the antibiotic choice should be adjusted (eg, trimethoprim-sulfamethoxazole or other current recommendations for your area). For animal bites, other antibiotics (eg, amoxicillin/clavulanate) may be more appropriate. Sepsis, advanced infections, or infections in persons with chronic medical problems (eg, diabetes, immunocompromised) should be managed with parenteral antibiotics and possible inpatient admission.
Postoperative Wound Infection. A patient with increasing pain and redness at the site of his staple closure. The area was erythematous, tender, warm, and had scant purulent drainage around some of the staples. (Photo contributor: Matthew D. Sztajnkrycer, MD, PhD.)
Wound dehiscence is managed conservatively by treating the underlying causes and allowing healing via secondary intention. Dehiscence of wounds in cosmetically sensitive areas is best managed in conjunction with a consultant. Myiasis is treated with wound cleaning and irrigation.
All accidental wounds are considered contaminated and treated as such. Thorough irrigation and cleansing is of paramount importance in preventing wound infection.
Expedient ED wound care is important since bacterial contamination increases over time.
Wound Dehiscence. After suture removal, the patient returned with dehiscence. The wound had a clean base of granulation tissue and was allowed to close by secondary intention. (Photo contributor: Alan B. Storrow, MD.)
Keloid. The degree of excessive scar bulk extending beyond the original wound margins may be dramatic and cosmetically significant. (Photo contributor: Thea James, MD.)
Wound Myiasis. Necrotic tissue can be invaded by fly larvae (maggots). (Photo contributor: Lawrence B. Stack, MD.)
Burns can be caused by heat, electricity, chemicals, friction, or radiation. Skin barrier damage can lead to infection, fluid loss, and electrolyte abnormalities. Long-term consequences include permanent scarring, loss of sensation, and in severe cases loss of extremities due to inadequate circulation.
Burns are assessed by determining the percentage of body surface area (BSA) involved, the depth, and the area of the body involved. A common system used to estimate BSA is following the “rule of nines.” This system breaks up the body into zones that each equate to 9% of BSA (see figure). Some clinicians use the palm of the patient’s hand as an equivalent to 1% BSA and measure the area involved by using this method.
First-degree burns only involve the epidermal layer. They are red, painful, and heal in approximately 1 week. Second-degree burns are subdivided into two categories, superficial partial thickness and deep partial thickness. Superficial second-degree burns extend from the epidermis to the superficial dermis. Pain, skin blistering, and intact capillary refill are characteristic. Deep partial thickness burns extend into the deep (reticular) layer of the dermis and damage hair follicles, sweat glands, and sebaceous glands. Blisters may occur, the exposed dermis is pale white to yellow in color, and capillary refill is absent. The entire thickness of the skin is compromised in third-degree burns. They appear pale, feel leathery, and are painless. Fourth-degree burns extend through the layers of the skin and involve muscle or bone.
Rule of Nines. Rule of nines is used to estimate the percentage of burn. (Reproduced with permission of Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. McGraw-Hill; 2011: Fig. 210-2, p. 1375.)
Second-Degree Burn. This patient has sustained a second-degree burn to his hand from hot oil. (Photo contributor: Suzanne Dooley-Hash, MD.)
Facial Burn, Second Degree. Ensuring that the patient has a protected airway in this type of injury is crucial. (Photo contributor: David Effron, MD.)
Management and Disposition
After resuscitation and stabilization, referral to a burn unit should be for partial thickness burns that involve greater than 10% BSA, third-degree burns, or involvement of the hands, feet, face, or perineum. Electrical burns, chemical burns, inhalation injuries, and patients with significant comorbidities should also be considered for a burn unit. Clinicians should cover the burned areas with a clean, dry sheet, administer aggressive pain control, and address fluid resuscitation. The Parkland formula is commonly used to estimate fluid requirements. The patient’s weight in kilograms is multiplied by the percent BSA involved; this number is multiplied by 4 mL of lactated Ringer solution. Half of this amount is given during the first 8 hours from time of initial injury and the remaining amount is given over the next 16 hours. It is recommended to keep urine output approximately 0.5 to 1.0 mL/kg/h. In order to monitor for effects of cell breakdown, urinalysis, creatine kinase, and an EKG should be obtained. Circumferential burns of the extremities may compromise circulation. If compartment syndrome is suspected, an escharotomy should be considered.
For minor burns, provide pain control, cleansing of the area, and application of topical antimicrobials (eg, 1% silver sulfadiazine, bacitracin, or triple-antibiotic ointment). Dressing changes should occur daily and patients must be instructed to watch for signs of infection. Follow-up with a burn-care expert needs to be arranged within a few days of discharge for deep partial thickness or third-degree burns.
Minor burns can be managed in the ED. Pain control, irrigation, antimicrobial ointments, and dressing changes are the mainstays of therapy.
Criteria for burn center referral should be reviewed for each patient (especially the young and elderly).
Extensive Burn Injury. Burns can be of varying depths; this patient has both second- and third-degree burns. Distal pulses should be closely monitored to guarantee that there is adequate circulation. (Photo contributor: David Effron, MD.)
Abdominal Burn. Mostly second-degree abdominal burn. (Photo contributor: R. Jason Thurman, MD.)