emDOCs.net Emergency Medicine (EM) Podcast

Episode 23: Wounds and Lacerations

March 02, 2021 emDOCs.net EM Crew Season 2 Episode 3
emDOCs.net Emergency Medicine (EM) Podcast
Episode 23: Wounds and Lacerations
Show Notes Transcript

Welcome to the emDOCs.net podcast! Join us as we review our high-yield posts from our website emDOCs.net.

Today on the emDocs cast with Brit Long, MD (@long_brit) and Manpreet Singh, MD (@MprizzleER) we cover wounds and lacerations in the ED.

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Brit: Welcome to the emDocs.net podcast. I’m Brit Long, and I’m joined by Manny Singh. Today we talk about wound laceration management pearls and pitfalls in the ED.

Manny: The evaluation and treatment of acute injuries accounts for millions of ED visits each year, where lacerations and other acute wounds are an important subset accounting for approximately 9 million seen yearly. These wounds require appropriate physical evaluation for extent of injury, radiographic evaluation for secondary injury, and irrigation & exploration for wound cleansing with removal of foreign body and debris.


Special considerations such as location and extent of injury as well as infection risk should be given to determine the optimal closure type and timing. Patients are at risk for infection, severe scarring, decreased mobility or diminished function, or prolonged pain if the emergency physician does not provide the proper initial treatment. 


Before we go further, Brit, what are some key questions with every wound?

Brit:


  • What emergent diagnoses should you consider in this patient?
  • What’s the neurovasular status?
  • What additional diagnostic testing should be considered in a wound close to a joint?
  • What are some factors that make this wound high risk for infection, and is tetanus up to date?
  • Could a foreign body be present?


Closure of the wound is performed to obtain a functional imitation of the body’s innate skin barrier for hemostasis and infection prevention. The pathway to healing occurs in sequential fashion; briefly summarized by a hemostatic phase which includes platelet aggregation and clot formation, a proliferative phase mediated by leukocytes, and the maturation and remodeling phases that gradually improve wound tensile strength and integrity (2). Infections, foreign bodies/debris, poor vascular supply, and large gaps can delay or prevent proper wound healing, so proper attention during evaluation and management by the emergency physician is paramount to decreasing the risk of infection and minimizing scar formation (2).

Manny: Evaluating the history of a wound is an important part of our initial evaluation. We have to consider factors such as the mechanism of injury, location, and length of injury, as well as the degree of contamination, time since injury, tetanus vaccination status, and any neurovascular or musculoskeletal deficits (3). The history helps determine whether imaging is necessary, may it be either X-ray, computed tomography, or ultrasonography.  The history can also help determine the extent of irrigation or debridement required, the utility of antibiotics and the need for specialist evaluation. 

If the mechanism of injury, location, depth, or deficits in movement/sensation is concerning for nonvisualized retained foreign body, bone involvement, joint involvement, compartment syndrome, or neurovascular injury, then advanced imaging would be most useful to ensure full evaluation of the extent of injury.

Plain radiography can identify metallic or other radiodense foreign bodies, determine if there is underlying bone cortex involvement or overt fracture, and can also diagnose an open joint if intra-articular air is seen. Ultrasound, either formal or point-of-care, can be useful in the identification of retained foreign bodies by providing information on depth, location, and orientation relative to the probe. 

A CT scan will allow for the most detailed evaluation- giving a 3-dimensional assessment that can visualize foreign bodies, bone injuries, joint involvement, vascular injuries, and muscle disruptions that need to be repaired. 

Imaging modalities, however, cannot diagnose compartment syndrome and the emergency physician should keep this possibility on their differential during initial and repeat evaluations.

Brit, what are other questions we should ask in our history?

Brit: Obtain tetanus vaccination history, and update as needed- for large, contaminated wounds ensure patient has had at least three prior doses and one within the last five years. If anyone has a contaminated wound and has not yet had three doses, they will require tetanus immunoglobulin in addition to an updated tetanus toxoid vaccine (2).

Another important factor in infection risk stratification is determined by a patient’s comorbid medical conditions, the level of vascular supply to the wound, (more blood supply leads to better infection control) and bacterial colonization of the skin itself (moist areas such as perineum, axilla, feet/hands are at higher risk of infection) (4). Immunocompromised patients- those on biologic agents or chemotherapy agents, chronic steroid use, and diabetic patients are automatically at higher risk for infection and poor wound healing. Patients with peripheral vascular disease also pose an infection risk, as a healthy blood supply is necessary to prevent infection (4). Injuries to moist body areas should increase the emergency physician’s concern for infection (4).

Manny: When it comes to cleaning wounds, let's discuss the Why, How and When?

Why? Wounds that present to the ED are dirty by definition, not the same clean incisions that surgeons often manage in the operating room. Removal of gross contamination of dirt, debris, foreign bodies as well as bacterial load begins with wound irrigation.

How? Start with wiping away visible contamination with dampened cloth to be able to visualize wound edges appropriately (5). Next let's irrigate the wound, but with what? Sterile water vs tap water? A recent RCT of over 600 patients in an ER setting showed no statistical difference between infection rates with sterile saline wound irrigation compared to tap water irrigation (6). The double-blinded study controlled for important factors including volume of irrigation, pressure and technique of irrigation. While a small study with an ultimate sample of 625, it is the largest study to date. Tap water is a safe option for wound irrigation and should be considered if cost or availability of sterile saline is an issue (6).

The pressure used to irrigate a wound has implications beyond cleaning and can lead to damage of the wound bed, wound edges, or vascular supply which can inhibit proper healing (2). A multitude of opinions exist to describe the optimal pressure for irrigation, but varied data results are available for consideration (20). A common rule seen is to aim for pressures of approximately 5 to13 psi- which is the pressure to break the adhesion between bacteria and surfaces (2). Multiple techniques have been described to obtain this pressure including irrigation caps attached to bottles or syringes, 18- or 19-gauge angiocatheters attached to 30-50cc syringes, or simply running the wound under tap water from the sink (2, 3). There is no evidence-based consensus on how to achieve optimal pressure during irrigation, so local practice habits should be taken into consideration (20).

The volume of irrigation is another debated topic, but is generally better agreed upon. The minimum recommendation is about 50-100cc solution per 1cm of wound. Adjust the amount of solution used based on the amount of contamination as necessary.

When? The earlier you can irrigate the wound, the better. Ideally irrigation is performed after anesthetizing to decrease pain and improve ability to fully explore wound (3). Do not let a delayed presentation to treatment prevent full irrigation and exploration.

 Brit: There are several types of closures

Primary is the most common type of closure. This involves immediate fixation of the deep and dermal layers with sutures, staples, adhesive tapes or tissue adhesive (8). This is the preferred method for the majority of acute lacerations that can be cleaned appropriately to optimize wound healing and infection prevention.

Delayed Primary as the name implies, involves a delay in wound closure to allow for evaluation at a later date. This is an approach consideration for contaminated, infected, old (>24 hours) or devitalized wounds (2). Devitalized wounds have areas of skin or tissue with compromised blood supply and are at risk of infection due to affected delivery of blood products.

Involves wound packing with return visit in 3-5 days after wound occurrence and decision to close with sutures, staples, adhesive tape, or tissue adhesive if no signs of infection are present.  This is a good method for older wounds or wounds at risk for infection (2). 

Secondary Intention involves the least amount of action, but most amount of patient education. Healing is unaided by sutures, staples, or adhesives (2). Allowing the body to heal by wound contraction- that is, healing from the inside/deepest layers out to the epidermal layer. This is a good method for infected or highly contaminated wounds (2). Instead of closing the skin around debris or bacteria, healing from the inside out allows contaminates to escape as the wound heals. This type of closure will result in scar formation as wound edges are not approximated, keep this in mind during your discussion with the patient.

What’s next Manny?

Manny: Anesthesia is an equally important part of wound repair. Local anesthetics typically work by disrupting sensory nerve conduction (8). Typically, ester or amide anesthetics are used, such as procaine, an ester, or amides such as lidocaine or bupivacaine. Warming anesthetics to body temperature can reduce the pain on injection (8). Other options for local anesthesia can include topical lidocaine-epinephrine-tetracaine (LET), benadryl, or ketamine (8). LET is frequently used in children but has application in adults as well (3). LET, however, is not readily available and requires local compounding at some shops. Diphenhydramine is an option for local anesthesia, however, is the least effective in terms of analgesia (8). Finally, local infiltration of ketamine has been shown to have as effective analgesia as bupivacaine (8).

Brit, what are the various ways we can close a wound?

Brit: Each wound can be closed by a variety of methods, including suture, staples, adhesive tape, tissue adhesive. Lets discuss the pros and cons of each.


Sutures
:

Pros: Provides the most amount of tensile strength – necessary for gaping wounds and wounds near moving joints

Cons: Non-absorbable, requires follow up for removal and time/precision/expertise at placement

Sutures vary based on type (non-absorbable vs absorbable), duration and tissue reactivity. We have a great table in the post that reviews this, so make sure you check it out.


Staples
:

Pros: Fair wound approximation, quick

Cons: Cosmesis/scarring is worse; requires follow up for removal


Adhesive tape
:

Pros: Quick, painless, good for skin tears; dissolves/falls off in 5-10 days with no follow up needed

Cons: Low strength, must remain dry, cannot be used on high tension wounds


Tissue adhesive (cyanoacrylate)
:

Pros: Quick, dissolves/falls off in 5-10 days with no follow up needed

Cons: Better for straight wounds, cannot be used for high tension wounds

Manny, let’s dive into some specific pearls and pitfalls for laceration repairs going from head to extremities

 Manny:


Scalp

Explore scalp wound for underlying skull fracture, and consider head CT scan based on the clinical picture and circumstances surrounding the injury. Large lacerations, blunt trauma, loss of consciousness, or current altered mental status are some examples to consider a head CT. The easiest closure method are staples as it provides a rapid closure with good strength in an area with low cosmetic concern (10). Simple interrupted, nonabsorbable sutures can also be a consideration if time permits, or cosmesis is concerning (e.g. hairless areas). 

When exploring scalp wounds, it is important to ensure the galea aponeurosis is intact and if not, repair it prior to superficial repair (11). The galea is the attachment of facial musculature, and therefore has an important role in maintaining facial structure and symmetry especially during facial expression. The closure is also needed to prevent the possible spread of infection through this potential space that is close to the skull (13). Galea closure is best performed with either 3.0 or 4.0 absorbable sutures in a simple interrupted manner. Staples or sutures on the scalp should be removed in 10-14 days  (10).


Forehead

Deep wounds to this area require muscle repair to preserve function- this is best achieved with simple interrupted stitches using 3.0 or 4.0 absorbable sutures followed by skin closure that can be done with simple interrupted 5-0 or 6-0 small sutures. Removal of the superficial sutures is done in 5-7 days.


Face

Eyelids: Examine the eyelids carefully for involvement to the canthi, lacrimal system, tarsal plate, or lid margin and any evidence of penetrating injury to the globe. If complex where there is  lacrimal involvement, or ptosis present consider ophthalmology consultation. Simple lacerations should be repaired with 6-0 or 7-0 nonabsorbable suture. Avoid adhesive in this area to prevent accidental eyelid closure or eyelash involvement. Remove sutures in 3-5 days.

Ears: Cartilage structures are at high risk for hematoma formation, which can lead to strangulation of the tissue and disfiguration. These are the cauliflower ears we see in our boxers, wrestlers and MMA fighters. Close wounds with 6-0 nonabsorbable sutures, ensuring coverage of all cartilage with skin but avoiding placement of sutures directly into cartilage. Apply pressure dressing to prevent hematoma formation- place gauze behind ear and wrap gauze circumferentially around head. There is a great EMDocs article for examples of compressive dressing linked in the post. Establish a wound recheck in 24 hours to assess for hematoma formation. Remove sutures in 5-7 days.

 Lip:  Intraoral lesions do not need to be sutured unless they are larger than 1cm or large enough for food to get stuck into. For lesions that penetrate through outside to inside or full thickness, close the mucosal layer first with absorbable suture, followed by muscular layer, and then finally skin. Involvement of the Vermillion border should be the first approximated suture on the skin layer- this is an essential skill for emergency physicians when closing lip lacerations. Use 6-0 suture to improve cosmesis. Remove skin sutures in 5-7 days (10,11).

Brit:


Arm, Hand 

It is important to assess the injury at rest as well as properly evaluate motor nerve/sensory nerve function, tendon function, and perfusion of the extremity distal to the wound during motion (12,13).

Fist Fight Injuries: Do not suture. Provide prophylactic antibiotics if there are not yet signs of infection- cover for polymicrobial infection sources including S. Aureus, Streptococcus spp., Corynebacterium spp., Eikenella corrodens with amoxicillin clavulanate (PO) or ampicillin/sulbactam (IV) or combination of clindamycin & ciprofloxacin for penicillin allergies. Patient requires follow up for wound check in 1-2 days; if signs of infection are present (or develop) patient will require IV antibiotics (12,13).

Flexor Tendon/Volar Injuries: Require urgent hand specialist for definitive repair- either consultation in ER or follow up within 24 hours depending on your local practice patterns. Tendon injuries are often missed, particular partial tendon injuries and lead to decreased hand function if not appropriately identified (14, 15). Clean wound and suture the skin- if tendon is not repaired immediately by a specialist, splint wrist and MCPs with flexion and PIPs/DIPs in extension and ensure timely follow up with hand surgeon (14).

Extensor Tendon/Dorsal Injuries: Can be repaired in ED, but will require follow up with hand specialist. Tendons should be repaired with 4-0 or 5-0 nonabsorbable suture in a figure-of-eight stitch to bring the cut edges together or closely approximated simple interrupted sutures. Splint hand in functional position with wrist in slight extension/ulnar deviation and MCP/DIP/PIPs in slight flexion for follow up with hand surgeon.


Manny:


Fingertips, Nails

Amputation: Pulp/skin loss with no exposed bone requires dressing changes only. Bone, joint, or tendon involvement requires hand specialist referral, with institutional dependent practices for closure or re-implantation. Reimplantation needs immediate referral and proper protection of the amputated digit. Wrap the amputated digit in moist gauze and place in a plastic bag, then place the bag in ice. However, do NOT place the digit directly on the ice. If only the distal tip (DIP) is amputated, this usually will not be replanted and will require revision amputation. Revision amputations can be done in the ER by using a rongeur to clip bone to below skin level and close skin flap over exposed bone (13). Prompt follow up with hand surgery should be secured.

Nail bed injuries: Trephinate subungual hematomas that occupy over half of the nail bed- use 18-gauge needle, cautery device, nail drill, or scalpel after proper anesthesia is obtained. Remove the nail if significant avulsion present to repair underlying nail bed laceration- retain the nail and suture back in place to keep the matrix open, or consider a malleable metal covering, such as the suture cover, that is conformed to the nail bed.


Leg, Foot

These wounds tend to be under higher tension and require more advanced suture techniques to provide support and allow the skin to come back together, such horizontal/vertical mattress sutures or deep dermal sutures. They are helpful for lacerations that are deep and involve muscles. The skin can still be approximated with staples if needed. Typically wounds in this location require a longer time, so suture / staple removal should happen after  10-14 days.

Brit, what are some can not miss diagnoses when it comes down to laceration repair?

Brit:

Open Fracture > visual inspection, Xray/CT; needs immediate antibiotics (first generation cephalosporin, add gentamicin if heavily contaminated), washout with orthopedics/trauma (15).

Open Joint > confirm with Xray/CT; needs immediate antibiotics  (again, first generation cephalosporin, add gentamicin if heavily contaminated), washout with orthopedics/trauma (15).

Compartment Syndrome > confirm with physical exam/suspicion; needs immediate fasciotomy/OR management.

Tendon injury > confirm with physical exam, CT scan; repair (if visible), splint and follow up with specialist vs specialist consultation (18).

Arterial injury/compromised vasculature > confirm with inspection, CT; control bleeding, vascular/specialist surgical consultation in ED.

Foreign body > visual inspection, Xray/CT/Ultrasound imaging; not all require removal if search risks damage to surrounding structures; small, inert, deep or asymptomatic foreign bodies can potentially stay; remove all reactive or contaminated foreign (thorns, wood, spines) immediately if possible (19).

Nerve injury > physical examination; assess before and after repair, needs specialist follow up for prolonged recovery monitoring.

Muscle injury > physical examination, CT imaging; needs repair to recover function, splint in functional position and follow up with specialist.

Human bite > history/visual inspection; always needs antibiotics, needs wound check follow up.

 Manny: That rounds out our summary of the key emDocs posts. Thanks for joining us on the podcast, and stay tuned for our next episode. Feel free to comment on our site and let us know if you have any feedback. Stay safe and healthy everyone!