Traumatic wounds are regularly encountered problems in the emergency department. It is important to document important historical information such as the mechanism, timing, location of injury, and the degree of contamination. Associated symptoms of pain, swelling, paresthesias, and loss of function should be identified. Determine factors that affect wound healing, such as patient age, location of injury, medications, chronic medical conditions, and previous keloid or scar formation. Adults with the sensation of a foreign body are much more likely to have retained a foreign body that should be removed. Review allergies, particularly to latex, and determine whether tetanus immunization is required (see Chapter 94). When caring for wounds, the ultimate goal is to restore the physical integrity and function of the injured tissue without infection.
When treating a wound, consider factors that impact risks for infection, such as time since injury, mechanism, and location. Shear forces are produced by sharp objects with relatively low energy, resulting in a wound with a straight edge and little contamination that can be expected to heal with a good result. Wounds caused by compression forces crush the skin against the underlying bone and often produce stellate lacerations. Tension forces may produce flap-type lacerations with surrounding devitalized tissue and may be more susceptible to infection. Other predictive factors for infection include location, depth, characteristics, contamination, and patient age. The risk of infection also relates to the interaction of bacterial contamination and blood supply. The density of bacteria is quite low over the trunk and proximal arms and legs, and thus these areas have lower risks for infection. Moist areas such as the axilla, perineum, and exposed hands and feet have a higher degree of colonization and may be at higher risk of infection. Wounds located on the face or scalp, both highly vascularized areas, are at lower risk for infection.
Wounds of the oral cavity are heavily contaminated with bacteria, although evidence supporting routine antibiotic use in simple intra-oral laceration is inconclusive. Wounds sustained from contaminated objects or environments and animal and human bites have an increased infection risk. Wounds contaminated with feces have a high risk of infection even when treated with antibiotic therapy. Although there is no clearly defined relationship between time to closure and infection rate, consider time since injury when making decisions about wound repair. Delayed primary closure after 4 days of open wound management is recommended for wounds with a high risk for infection during the first care encounter.
DIAGNOSIS AND DIFFERENTIAL
Wound examination is greatly facilitated by a cooperative patient, good positioning, optimal lighting, and little or no bleeding. A thorough examination will minimize the risk of missed foreign bodies, tendon injuries, and nerve injuries. While performing wound assessment, repositioning the joint or extremity in the position assumed during injury may help identify underlying damaged structures.
Assess wound location, size, shape, margins, and ...