Chapter 18: WOUNDS AND SOFT TISSUE INJURIES

Clinical Summary

The goals of minor wound care are to achieve optimal wound aesthetics and infection prevention. For most uncomplicated wounds, irrigation is the most effective means of reducing bacterial count. However, debridement may be necessary in contaminated wounds since devitalized tissue may impair the wound’s ability to resist infection.

Management and Disposition

Preliminary wound management begins with assessment, adequate hemostasis, foreign-body removal, and irrigation. Provide adequate analgesia prior to wound cleansing. In simple well-vascularized wounds, tap water is as effective as normal saline or sterile water. In contaminated wounds, povidone-iodine diluted 1:10 with normal saline may help with disinfection. Bacterial-static solutions, such as nonionic surfactant cleaner, may also reduce bacterial inoculum. Solutions containing ionic detergents (eg, Betadine surgical scrub) should not be used as it is toxic to wound tissue. If necessary, wound scrubbing should be done gently to avoid damaging viable tissue.

Irrigation is the most effective means of reducing bacterial inoculum; 500 to 1000 mL of fluid or 60 mL/cm of wound length is adequate for most uncomplicated wounds. The recommended irrigation pressure of 5 to 8 lb per square inch (PSI) can be accomplished by attaching an 18- or 19-gauge intravenous (IV) catheter sheath, or a commercially available splash shield, to a 20- or 30-mL syringe. A bulb system is suboptimal; it generates only 0.5 to 1 PSI. Debris that cannot be irrigated can be scrubbed or sharply debrided. The tissue should appear pink and viable; a scant amount of fresh bleeding indicates good vascular supply. High-pressure irrigation (≥25 PSI) may be necessary in highly contaminated or complicated wounds requiring operating room washout. However, it offers no advantage for routine wounds.

Pearls

1. Universal precautions, including gloves and face shield, should always be observed.

2. Antibiotics are no substitute for thorough wound cleansing and irrigation.

3. Shaving the eyebrow for wound repair is contraindicated due to the unpredictable pattern of hair regeneration.

Clinical Summary

Proper wound assessment and preparation are essential to good wound management. Always consider the age and mechanism of injury, risk for contamination or foreign body, risk to the nerve, blood vessel and tendon, tetanus status, and identifying comorbid conditions that may affect wound healing.

Management and Disposition

Patient compliance is integral to achieving adequate wound exploration. The use of local or regional anesthesia is usually sufficient. However, procedural sedation may be required in some. Document neurovascular status prior to any anesthetic administration. Application of direct pressure is often the easiest way to achieve hemostasis. Other methods include the use of blood pressure cuff or tourniquet to achieve temporary hemostasis. Anesthetic solution containing epinephrine (1:100,000 dilution) may help constrict small vessels; however, particular caution should be exercised when using any vasoconstrictors in areas of end arterial circulation (eg, fingers, nose, toes, ears, and penis).

While hemostats or other self-restraining devices such as retractors may help achieve adequate exposure, care must be exercised to avoid damaging the dermis and the tissue’s vascular integrity. If exposure is still not adequate despite hemostasis and separation, the wound margins may be slightly extended with fine iris scissors or scalpel to allow better visualization. The wound is extended from one end, through the epidermis and dermis only, to avoid further injury to underlying structures. Once the superficial fascia has been exposed, it may be carefully and bluntly dissected using forceps or scissors.

Pearls

1. Never probe a wound blindly or blindly attempt to control bleeding with hemostats.

2. At 1:100,000 dilution, epinephrine-containing anesthetics may be used with caution in areas of end arterial circulation such as the ear, fingers, nose, toes, and penis.

3. If epinephrine-induced tissue ischemia occurs, injection of phentolamine around the area of ischemia may help restore flow.

Clinical Summary

All foreign bodies can become a nidus for delayed infection. All reasonable attempts should be made to remove them. Radiographic evaluation or ultrasound (see related chapter) may assist in locating foreign bodies not directly visualized. Foreign bodies are characterized as being either reactive (eg, organic materials such as wood, bone, and soil) or nonreactive (eg, glass and metal).

Management and Disposition

Patients are often unaware that a foreign body is present in their wound; a high level of clinical suspicion should accompany any injury pattern at risk for foreign-body penetration. Wounds at increased risk for foreign-body penetration include lacerations caused by broken glass, perioral injuries with loss of dentition, and injuries to the hands and feet involving needles, nails, or splinters.

Suspicion of a retained foreign body mandates local wound exploration and the consideration of radiographic or ultrasound evaluation. Nearly 80% of objects can be identified on plain radiographs. More specifically, approximately 90% of glass fragments greater than 2 mm in size can be identified through the use of plain radiographs; fragments as small as 0.5 mm can be identified in 50% to 60% of cases. In situation where plain radiographs are poor, ultrasound may be considered.

Due to their increased risk for delayed infection and poor wound healing, reactive material must be removed. Nonreactive objects, however, may be left in place if reasonable effort to remove it has been unsuccessful, and no potential for harm to a vital structure exists. Glass, however, has the potential for significant irritation and a removal attempt should be pursued.

Pearls

1. The base of the wound must be visualized as many foreign bodies hide there.

2. Common foreign bodies retained in hand wounds are wood splinters, glass fragments, metallic objects, and needles.

3. Missed retained foreign bodies are a very common source of litigation in emergency medicine.

Clinical Summary

Traumatic surface wounds are caused by one of three mechanisms: shearing, tension, or compression. Such a division helps to guide management decisions involving infection risk and scar formation.

Shearing injuries are caused by sharp objects, such as glass shards or knives, which impart low-energy injury and minimal tissue destruction. A majority of uncomplicated shearing injuries (ie, those not involving neurovascular or anatomically important structures) are repaired primarily in the emergency department (ED). The risk of infection is low and scar formation is typically cosmetically acceptable. Puncture wounds occur from sharp objects that pierce the skin and penetrate into deeper tissues. Such wounds are at a higher risk for infection, foreign-body retention, and underlying structural injury.

Tension or partial avulsion injuries occur when an object strikes the skin at a sharp angle creating a triangular flap. This results in potential vascular disruption, greater tissue destruction, and a higher risk for infection and tissue ischemia. During the repair, vascular supply to the flap must be meticulously preserved; otherwise, the flap may become ischemic.

Crush or compression injuries occur when a blunt object strikes tissue at a right angle, imparting a high degree of kinetic energy. This results in significant tissue destruction of the skin and its underlying supportive fascial layers. Crush injuries are typically ragged, with irregular wound edges and a complex laceration pattern. Despite meticulous wound care and careful primary closure, the resulting scars may be cosmetically poor.

Management and Disposition

First update the tetanus status of all patients requiring wound management. Carefully document the time and functional/neurovascular status at initial evaluation, as this may change over time. Upon optimizing wound preparation, appropriate closure tension must be achieved. If open fracture is suspected or confirmed, IV antibiotics are administered and orthopedic consultation obtained. Repair of traumatic wounds depends on the depth, complexity, and location. Deep wounds are closed in layers or by using a vertical mattress technique to remove dead space and relieve tension. Superficial wounds may be repaired with staples, simple interrupted sutures, or running sutures. In certain circumstances, the use of adhesive skin closures or adhesive glues may be adequate.

Pearls

1. Simple, uncontaminated, and uncomplicated wounds caused by clean, sharp objects in otherwise healthy patients may undergo primary closure up to 18 hours from the time of injury with good cosmetic result (see Simple Wound Closures).

2. The vascular supply to a flap is often tenuous; improper closure may further compromise the tissue, especially at the tip. A repair using a corner stitch will help minimize further ischemia (see Complex Wound Closures).

3. Crush injuries have an increased susceptibility to infection. Thorough cleansing, copious irrigation, and judicious debridement are required.

Clinical Summary

The ear is composed of a poorly vascularized cartilaginous skeleton covered by tightly adherent skin. Given the paucity of subcutaneous tissue, ear injury that results in hematoma formation can cause pressure necrosis of the cartilage. The goal of repairing an ear laceration involves completely covering the exposed cartilage and preventing hematoma formation.

Management and Disposition

Prior to repair, the area is examined for signs of acute hematoma formation or other associated traumatic injuries. Hemotympanum or Battle sign suggests the presence of a more serious closed head injury, especially basilar skull fracture. Blunt trauma may result in barotrauma resulting in tympanic membrane perforation. Examination can be facilitated by local anesthesia infiltration or, in the case of larger or more complex lacerations, a regional nerve block.

Simple lacerations through the earlobe or the helix can be repaired with interrupted 6-0 nonabsorbable monofilament sutures if the cartilage is not exposed. Simple lacerations that involve the cartilage are primarily repaired by ensuring complete coverage of the exposed cartilage by careful apposition of the overlying skin. The skin generally provides sufficient support, so sutures are not required for the cartilage itself. If the wound is sufficiently irregular and cartilage debridement becomes necessary to avoid undue wound tension, the debridement should be kept to a minimum.

A perichondral hematoma must be drained within 72 hours to prevent potential pressure necrosis which can result in a “cauliflower” ear. Ear wounds are best dressed with a mastoid pressure dressing either primarily or after later hematoma drainage. Such a dressing reduces the chances for future hematoma formation and its complications. Ear sutures are removed in 4 to 5 days.

Pearls

1. Epinephrine-containing anesthetic at a 1:100,000 dilution may be used in ear laceration repair.

2. Hematoma evacuation needs to be rechecked in 24 hours to evaluate for reaccumulation.

3. If cartilage has been exposed or a hematoma drained, antistaphylococcal antibiotic coverage is recommended.

4. Complex lacerations and hematomas of the ear are best cared for in conjunction with a consultant.

Clinical Summary

Lip lacerations may result in significant cosmetic defects if not properly repaired. The lip has two significant anatomic landmarks: the mucosal border, which divides intraoral and external portions of the lip, and the vermilion border, which separates the lip mucosa from the skin of the face. Meticulous alignment of the vermilion border and its associated “white line” is the cornerstone of cosmetic repair. Lip anatomy may be distorted by the kinetic energy of the impact as well as the resultant edema surrounding the wound. Lacerations of the lip’s vermilion border may be partial- or full-thickness, compromising the underlying orbicularis oris.

Management and Disposition

Given the high bacterial content of the oral cavity, lip lacerations will not remain clean during repair. The goal of irrigation is to remove clotted blood and gross contaminants such as tooth fragments or dirt. If a fractured tooth is noted, the wound must be explored for fragments. If the tooth or fragment is unaccounted for, then a Panorex or soft tissue radiograph of the face and a chest radiograph should be obtained. Anesthesia for laceration repair is best performed using either an infraorbital (upper lip) or mental (lower lip) nerve block since local infiltration often distorts the tissue and impairs proper alignment of the vermilion border.

If the vermilion border is violated by a superficial laceration, then the first suture, typically 6-0 in size, is placed at the border to reestablish anatomic relationships. Once alignment is judged adequate, simple interrupted sutures are used for completion. If the laceration extends within the oral cavity, absorbable 5-0 sutures are used to close the intraoral component.

With deep or “through and through” lacerations involving the orbicularis oris, the muscle layers are initially approximated with deep, usually 5-0, absorbable sutures. Once the muscle is approximated, the first skin suture is again placed at the vermilion border.

Sutures are removed in 3 to 5 days in children, 4 to 5 days in adults. The patient is advised to eat soft foods, not to apply excessive force to the suture line, and to rinse after eating to prevent the accumulation of food particles.

Pearls

1. Misalignment of the vermilion border by as little as 1 mm may result in a cosmetically noticeable defect.

2. A marking pen may be used to identify landmarks prior to placing the sutures, as suturing itself causes some tissue edema, bleeding, and distortion.

3. Any patient with a lip laceration requires a thorough inspection of the oral cavity for associated trauma, including dental fractures, oral lacerations, and mandibular injuries.

Clinical Summary

Tendon injuries are often associated with hand or wrist lacerations. Accurate assessment requires documentation of both motor function and strength. Partial tendon ruptures, including near complete, may still result in normal function.

Management and Disposition

Prior to wound exploration, a thorough exam is performed to assess neurovascular and motor function. All individual flexor and extensor tendons are assessed, including deep and superficial. Abnormal resting posture of the involved extremity can also indicate tendon injury. Tendons are taken through a full range of motion, including re-creation of limb position at the time of insult, in order to detect injuries along the tendon length. Adequate exploration requires excellent hemostasis achieved through direct pressure, or use of a blood pressure cuff or other tourniquet. Initial wound care should include irrigation, exploration for foreign bodies, debridement, antibiotics, and tetanus prophylaxis if indicated.

Partial tendon lacerations are treated conservatively, with splinting in neutral position and follow-up. Isolated extensor tendon lacerations may be repaired in the ED with subsequent specialist follow-up. Flexor tendon lacerations generally require consultation with a hand surgeon or orthopedic surgeon.

Pearls

1. While extensor tendon repair may be accomplished by an emergency care physician with appropriate training and experience, flexor tendon lacerations are a challenging orthopedic problem and require referral.

2. Flexor tendons are weakest approximately 3 weeks after repair.

3. Inability to flex the distal phalanx with intact proximal phalanx extension suggests a flexor digitorum profundus disruption.

Clinical Summary

Bite wounds (abrasions, lacerations, and punctures) are a frequent emergency care challenge, although most are minor. Dog bites account for the vast majority, followed by cats, humans, and, rarely, other animals (raccoons, foxes, livestock, etc).

Bite wound microbiology is frequently polymicrobial with mixed aerobic and anaerobic bacteria. Pasteurella multocida (a gram-negative anaerobe) has been cultured from up to 80% of cat bites and 25% of dog bites. Eikenella corrodens has been recovered from human bites. Capnocytophaga canimorsus (formerly known as DF-2), a virulent organism which can be normal oral flora in dogs (16%) and cats (18%), can lead to sepsis, disseminated intravascular coagulation, gangrene, or death in susceptible individuals (eg, immunocompromised, asplenic, or diabetic).

The primary site of a bite wound in adults is on the extremities. The hand is at highest risk for developing infection, while the face is the most infection-resistant. Puncture wounds, especially from cats, are also prone to infection. Simple abrasions, regardless of animal, are unlikely to become infected with proper wound care.

Management and Disposition

Management depends on location, animal involved, time elapsed before presentation, and wound type. All wounds should be thoroughly cleaned and debrided. Radiographs should be obtained to exclude bony injury or retained dentition. Contusions and superficial abrasions can be treated with local wound care.

Recommendations vary regarding timing of wound closure. Closure of facial and head wounds can be performed up to 12 hours (and in some reports up to 24 hours). Puncture wounds (especially if caused by a cat), hand lacerations, or high-risk wounds (wounds > 12 hours or clinically infected) should be considered for delayed primary closure. While a linear incision over a puncture wound may facilitate cleaning and exploration, efficacy of this is questioned. Human bites to areas other than the face and head should generally be left open and considered for delayed primary closure. Hand injuries caused by human bites are left open and managed in consultation with a hand specialist (see Chapter 11, Extremity Trauma, Clenched Fist Injury). One should maintain a high index of suspicion for human bite in any laceration near the metacarpals.

All sutured bite wounds should be reevaluated by a healthcare provider within 24 hours. Closed wounds which appear infected on reevaluation should be opened, irrigated, and allowed to close by secondary intention. Cyanoacrylate adhesives should never be used to close a bite wound.

Antibiotic therapy recommendations for bite wounds differ widely. Antibiotics are not recommended for minor wounds. They are recommended for cat bites, hand wounds, and in persons with chronic diseases (eg, diabetes). Empiric therapy is started with broad-spectrum antibiotics such as ampicillin-sulbactam, cefoxitin, or ceftriaxone. Alternatively, ciprofloxacin (or trimethoprim-sulfamethoxazole in children) and clindamycin can be used. Infection by P multocida classically becomes apparent within 24 hours of the bite and is marked by prominent pain, erythema, and swelling. Amoxicillin-clavulanate is the suggested regimen to cover polymicrobial infections and infections caused by P multocida or C canimorsus. Cultures are not recommended for initial treatment. However, they should be obtained in any wound worsening during antibiotic therapy. Tetanus immunization should be appropriately updated.

Rabies infection is rare in the United States; worldwide, dogs are the number one reservoir (see Chapter 21, Tropical Medicine, Rabies). Carnivorous animals (eg, raccoons, skunks, foxes, dogs, or bats) are more likely to be infected. If an animal is suspected as rabid, it should be detained and observed for any signs of rabies; occasionally this requires euthanasia and necropsy. Bats require special attention as many people do not recall being bitten. Healthcare professionals should have a low threshold for instituting rabies prophylaxis in persons with a bat exposure or in whom the animal is not available. Local animal control offices can be contacted for recommendations on appropriate rabies prophylaxis measures.

Pearls

1. All patients with bite wounds from susceptible animals (especially bats) should be assessed for rabies exposure.

2. Given cosmetic concerns and low infection risk, dog bites to the head and face can generally be sutured up to 24 hours after appropriate irrigation.

3. Bites which become infected within 24 hours, especially from cats, should be assumed to be caused by P multocida.

Clinical Summary

Fishhook barbs often prevent backing the hook out of the puncture site. Several different methods have been described for removal.

Management and Disposition

Adequate anesthesia, usually local, is essential for removal. Procedural sedation may be needed if a child has a fishhook embedded in a sensitive area (eg, eyelid).

The method used to remove the hook depends primarily on the location of the barb relative to the skin surface and the body part embedded. The most common removal technique is the “push-through and cut.” This is recommended when the tip of the fishhook is close to breaking through the skin surface after being embedded (see figures). Care should be taken when performing this maneuver in the hand or face as pushing the fishhook forward may damage nearby structures.

Superficially embedded hooks or hooks with small barbs may be removed in a retrograde fashion, by exerting pressure on the fishhook shaft toward the barb and backing the hook out through the original site of penetration. This technique can be performed manually or with the use of a string.

Once fishhooks are removed, the wound should be cleaned, irrigated, and left open. Antibiotics are usually not necessary; however, treatment (doxycycline) for Vibrio species (especially Vibrio parahaemolyticus) should be considered in wounds contaminated with saltwater.

Pearls

1. Hooks embedded in cartilaginous structures, such as the ear or nose, are best managed with the push-through methods.

2. Hooks that penetrate joint spaces or bone should be managed in consultation with orthopedics.

3. Fishhooks that penetrate the globe of the eye are left in place and emergent ophthalmologic consultation is obtained. The patient is placed in the semirecumbent position and the globe is protected with an eye shield. Pressure patches are contraindicated, as they may extrude intraocular contents.

Clinical Summary

Most ED lacerations are uncomplicated and can be repaired primarily. Complications (dehiscence, infection, improper healing, scarring) can be minimized by proper suturing techniques, including good wound edge approximation and decreasing wound tension. Wound edge eversion is also essential for proper healing as the edge will flatten with time.

Management and Disposition

Suture techniques must be individualized depending on physician’s skill, laceration type, and location. Suture material, size, and duration before removal are determined by anatomic site (Table 18.2).

Deep interrupted absorbable sutures are used, if necessary, to reduce wound tension before superficial repair. Start the deep suture from the bottom of the wound, continue across the top (subdermally), and return to the bottom in finishing. This will leave the knot at the bottom of the wound, decreasing the chance suture material will exit at the surface.

Simple interrupted closures involve single nonabsorbable sutures, each independently tied. The needle should penetrate the skin at 90 degrees and exit the other side of the wound at 90 degrees.

Staples are a rapid means of closing linear wounds. They should not be used on the hands, feet, face, or over joints. Wound edge eversion is also critical to obtain the best outcome.

Running closure is a rapid technique using several bites along the length of a wound without tying individual knots. Knots are tied only at the beginning and end.

Liquid wound adhesives (eg, cyanoacrylate) have advantages due to speed and lack of a repeat visit for suture removal. Anesthesia may not be required. Small linear lacerations are ideal. The wound must be dry and free of active bleeding for proper adhesion. Antibiotic ointment should not be applied as this will dissolve the adhesive.

Elastic wound closure strips have the same advantages and indications as adhesives. They can be used alone or in conjunction with a tissue adhesive (benzoin resin) applied to the skin on either side of the wound. The edges will curl up over time and can be trimmed by the patient as needed, until they fall off in 2 to 3 weeks. They can also be used after suture removal to give the wound more time to gain tensile strength. Wound closure strips are not recommended in children as they have a tendency to remove them prematurely.

Pearls

1. The bites on both sides of a wound should be equidistant for both optimum wound healing and cosmetic outcome.

2. In gaping wounds, surface tension should be reduced with deep sutures.

3. Antibiotic ointment may be used to remove the adhesive from areas unintentionally glued together by cyanoacrylate.

Clinical Summary

Horizontal and vertical mattress sutures, as well as the corner stitch (see figures for technique), may be used to manage wounds unable to be closed with simple techniques.

Management and Disposition

Vertical mattress suture is a useful technique for deep wounds. It reduces wound tension by acting as both a deep and superficial suture.

Horizontal mattress suture is best used for wide, gaping wounds with a risk of increased wound tension after closure (eg, lacerations overlying a joint).

Corner stitch is used to close triangular wounds or flaps. A simple interrupted suture cannot be placed to approximate the point of the flap due to a tenuous blood supply and increased chance of dehiscence. Once the corner is secured, simple sutures are used to repair the rest of the wound, with care taken to place the sutures far enough from the tip to optimize circulation.

Pearls

1. Utilization of a mattress suture can aid in wound edge eversion and tension reduction. They are particularly useful in areas where the deep subcutaneous tissues are too fragile for deep sutures (eg, over a joint or shin).

2. A single corner stitch may be used to close several corners of a stellate wound.

Clinical Summary

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.

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.

Pearls

1. All accidental wounds are considered contaminated and treated as such. Thorough irrigation and cleansing is of paramount importance in preventing wound infection.

2. Expedient ED wound care is important since bacterial contamination increases over time.

BURNS

Clinical Summary

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.

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.

Pearls

1. Minor burns can be managed in the ED. Pain control, irrigation, antimicrobial ointments, and dressing changes are the mainstays of therapy.

2. Criteria for burn center referral should be reviewed for each patient (especially the young and elderly).

Clinical Summary

Electricity generates heat through tissue resistance or directly by the current on cells. Many factors affect injury severity: type of current (DC or AC), intensity, duration, tissue resistance, and pathway through the body. When electricity traverses the tissues, it may cause contact burns, thermal injury, muscular tetany, or severe contraction. Sudden death (asystole, respiratory arrest, ventricular fibrillation), myocardial damage, myoglobinuria, compartment syndrome, and various metabolic disorders have also been described.

High-voltage DC or AC current typically causes a single violent muscular contraction and throws the victim from the source; blunt trauma and blast injuries may occur. Low-voltage AC currents (as from a household outlet) typically cause muscular tetany, forcing the victim to continue contact with the source.

Management and Disposition

After initial stabilization, consider cervical spine immobilization, oxygen administration, cardiac monitoring, and IV crystalloid infusion. A Foley catheter will help monitor urine output and is especially important if rhabdomyolysis is suspected. Diagnostic testing to consider includes: electrocardiogram (ECG), complete blood count (CBC), urinalysis, CPK, CPK-MB, electrolytes, BUN, creatinine, and coagulation profile.

Severe or high-risk injuries should be admitted to a burn unit, or trauma center with burn consultation. Patients with minor, brief, low-intensity exposures, with a normal ECG, normal urinalysis, and no significant burns or trauma may be considered for discharge after a period of observation.

Pearls

1. Toddlers are at increased risk of labial injury from chewing on electrical cords.

2. High-risk features include high-voltage exposure (>600 V), deep burns, neurologic injury, dysrhythmias, abnormal ECG, evidence of rhabdomyolysis, suicidal intent, or significant associated trauma.

Clinical Summary

Decubitus ulcers develop when soft tissue is compressed between a bony prominence and a hard external surface. Tissue compression results in decreased blood flow, tissue ischemia, and cell death. Pressure, shearing forces, friction, and excessive moisture contribute to formation. Areas commonly affected include the sacrum and heels. Immunocompromised, nursing home, neurologically impaired, and immobilized trauma patients are at high risk.

Stage I ulcers are characterized by an area of nonblanchable erythema over intact skin. Stage II appears as a shallow, open sore with a pink wound base. When the wound is full thickness with no muscle, tendon, or bone exposed, it is defined as stage III. If muscle, tendon, or bone is exposed, it is stage IV. Some wounds may have an area of black eschar over them; these wounds cannot be categorized since injury depth cannot be determined.

Management and Disposition

Prevention is key. All patients who have decreased mobility, such as trauma and nursing home patients, should have their entire skin surface regularly checked for skin breakdown and should be repositioned frequently. Backboards, c-collars, and other immobilizing devices should be removed as soon as possible.

Treatment includes pain relief, keeping the affected area clean, and keeping pressure off the area to prevent further tissue destruction. There are multiple commercial products available (hydrocolloid dressings) to use for the treatment of pressure ulcers. Frequent monitoring is required and consultation with wound care specialists or a surgeon may be necessary for advanced ulcers. The main complications of decubitus ulcer formation include infection and skin dehiscence.

Pearls

1. Decubitus ulcers are divided into four stages. If an eschar is present, the ulcer cannot be categorized.

2. Remove hard external surfaces and immobilizing devices as soon as possible.