Updated: 1/1/2022

Wound Management

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  • Snapshot
    • A 45-year-old man presents to the ED after being blown into a wall following a gas explosion. Due to extensive evidence of lacerations and intraabdominal injuries, he is emergently taken to the OR for exploratory laparotomy. He undergoes splenectomy and partial colectomy with colostomy. Once negative pressure vacuum wound dressings are applied and hemodynamic stability is attained, the patient is taken to the surgical intensive care unit. On the fourth postoperative day, the nurse reports redness and tenderness along the patient's incision margins. The patient is taken back to the OR, where purulent material is drained and nonviable tissue along the margins are debrided.
  • Introduction to Wound Management
    • In trauma setting, challenge is to identify all injuries, both obvious and non-obvious
      • triad of management is control of bleeding, pain, infection
  • Presentation
    • Types of wounds and stages of wound healing affect management
      • laceration
        • cut or torn tissue caused by tearing mechanism
      • abrasion
        • superficial graze caused by rubbing or scraping mechanism
      • contusion
        • bruise caused by high-force mechanism
        • outer layer of skin is intact but injured
      • avulsion
        • "degloving" injury that forcefully separates skin/soft tissue from underlying tissue
      • puncture
        • tissue torn by puncturing mechanism (including bites)
      • crush injury
        • tissue injury due to high-pressure mechanism
      • thermal/chemical wound (i.e., burns)
  • STUDIES
    • Primary and secondary survey with resuscitation
      • all clothing must be removed to visualize all possible lesions
      • all structures deep to a laceration is considered injured until proven otherwise
        • evaluate functional and neurovascular status distal to all lesions
        • use radiography or ultrasound for any suspected foreign bodies
      • evaluate for coagulopathy (e.g., family history, liver disease) and anticoagulant use
      • consider amputation if blood supply or soft tissue severely compromised
  • Management
    • Focus on control of bleeding, pain, potential infection
    • Bleeding
      • obtain hemostasis quickly
      • fluid resuscitation as necessary
      • drain all hematomas
    • Pain
      • local anesthetic (e.g., lidocaine)
      • systemic analgesic (e.g., morphine)
      • systemic anesthesia (e.g., propofol)
    • Infection
      • for all wound types, cleaning as early as possible with irrigation and exploration for foreign bodies
      • abrasions: antiseptic ointment for facial abrasions especially
      • prophylactic antibiotics for animal/human bites, intraoral lesions, puncture wounds to foot
      • tetanus prophylaxis (see chart below)
        • based on wound type (clean/dirty), age, and immunization history
        • age
          • < 7 years: DTaP
          • 7 - 64 years: Tdap
          • > 65 years: Td
    • Amputated body parts
      • wrap amputated body part in saline-moistened sterile gauze and seal in a sterile plastic bag
      • cooling prolongs opportunity for replantation and increases probability of replantation success
        • 6 hours of cold ischemia = 1 hour of warm ischemia

    • Clean, Minor Wound
      All Other Wounds
      Vaccination history
      Vaccinate Based on AgeTetanus ImmunoglobulinVaccinate Based on Age Tetanus Immunoglobulin
      Unknown of < 3 dosesYesNoYesYes
      ≥ 3 doses
      Only if last dose > 10 years agoNoOnly if last dose > 5 years agoNo
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Questions (2)

(M3.OR.16.8) A 35-year-old man is brought into the emergency department by emergency medical services with his right hand wrapped in bloody bandages. The patient states that he is a carpenter and was cutting some wood for a home renovation project when he looked away and injured one of his digits with a circular table saw. He states that his index finger was sliced off and is being brought in by his wife. On exam, his vitals are within normal limits and stable, and he is missing part of his second digit on his right hand distal to the proximal interphalangeal joint. How should the digit be transported to the hospital for the best outcome?

QID: 102607

Wrapped in a towel

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In a sterile bag of tap water

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In a sterile plastic bag wrapped in saline moistened gauze

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(3/28)

In a sterile plastic bag wrapped in saline moistened gauze on ice

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(23/28)

In the pocket of a coat or a jacket

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M 11 D

Select Answer to see Preferred Response

(M3.OR.15.3) A 54-year-old male carpenter accidentally amputated his right thumb while working in his workshop 30 minutes ago. He reports that he was cutting a piece of wood, and his hand became caught up in the machinery. He is calling the emergency physician for advice on how to transport his thumb and if it is necessary. Which of the following is the best information for this patient?

QID: 102602

Place thumb directly into cooler of ice

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(5/15)

Place thumb in cup of cold milk

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Wrap thumb in sterile gauze and submerge in a cup of saline

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(1/15)

Wrap thumb in saline-moistened, sterile gauze and place in sterile bag

53%

(8/15)

There is no need to save the thumb

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M 11 E

Select Answer to see Preferred Response

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