Wound Care


Goals of ED Treatment
  • Identify injuries and stop any active bleeding - direct pressure
  • Manage pain
  • Wound examination and exploration (history and physical)
  • Cleansing +/- antibiotic and tetanus prophylaxis
  • Repair and dressing
Tetanus Prophylaxis
  • both tetanus toxoid (Td) and immunoglobulin (TIG) are safe (and indicated) in pregnancy
Table 9. Guidelines for Tetanus Prophylaxis for Wounds1 
wounds >6 hours old, >1 cm deep, puncture wounds, avulsions, wounds resulting from missiles, crush wounds, burns, frostbite, wounds contaminated with dirt, feces, soil, or saliva 
2 0.5 mL IM tetanus and diphtheria toxoids (Td), adsorbed 
3 tetanus immune globulin (TIG), 250 units deep IM
Source: MMWR 2001; 50(20); 418, 427. MMWR 1991; 40(RR12); 1-52.
 
Immunization History Non Tetanus 
Prone Wounds
Non Tetanus 
Prone Wounds
Tetanus 
Prone Wounds
Tetanus 
Prone Wounds

 
Td2 TIG3 Td TIG
Uncertain or <3 doses Yes No Yes Yes
3 or more
none for >10 years
Yes No Yes No
3 or more,
>5 yr but <10 years ago
No No Yes No
3 or more
< 4 years ago
No No Yes No

Risks for Tetanus
Wound Characteristics        Tetanus-Prone Not Tetanus-Prone
Time since injury >6 hrs <6 hrs
Depth of injury >1 cm <1 cm
Mechanism of Injury Crush, burn, gunshot, frostbite, puncture through clothing, farming injury Sharp cut  (e.g. clean knife, clean glass)
Devitalized tissue Present Not present
Contamination (e.g. soil, dirt, saliva, grass) Yes No
Retained foreign body Yes No

 

A large wooden splinter went deep into the forearm of a 24-year-old male while he was working in a horse barn, and he has required local anesthesia and a small incision to remove it completely. After thorough wound cleansing, you inquire about his tetanus status. He is certain that he received all of his primary childhood vaccines and a “tetanus booster” at age 20, but does not know which vaccine he received.
Which one of the following is the best choice for this patient regarding tetanus immunization at this time?

A) TT (tetanus toxoid)
B) Td (tetanus toxoid with reduced diphtheria)
C) Tdap (tetanus toxoid with reduced diphtheria and acellular pertussis)
D) TIG (tetanus immune globulin)
E) No immunization


ANSWER: E

  • The Advisory Committee on Immunization Practices (ACIP) periodically makes recommendations for routine or postexposure immunization for a number of preventable diseases, including tetanus. Since 2005, the recommendation for tetanus prophylaxis has included coverage not only for diphtheria (Td) but also pertussis, due to waning immunity in the general population. The current recommendation for adults who require a tetanus booster (either as a routine vaccination or as part of treatment for a wound) is to use the pertussis-containing Tdap unless it has been less than 5 years since the last booster in someone who has completed the primary vaccination series.

    In this scenario, no additional vaccination is needed at this time, since the patient is certain of completing the primary vaccinations and received a tetanus booster within the previous 5 years. Had the interval been longer than 5 years, then a single dose of Tdap would be appropriate unless his previous booster was Tdap. Tetanus immune globulin is recommended in addition to tetanus vaccine for wounds that are tetanus-prone due to contamination and tissue damage in persons with an uncertain primary vaccine history. Plain tetanus toxoid (TT) is usually indicated only when the diphtheria component is contraindicated, which is uncommon.

Mnemonic

Acute treatment of contusions (RICE):
Rest
Ice
Compression
Elevation

Clinical Pearl
Suture To Close with Ethalon or other non-absorbable suture Approx. Duration (days)
Face 6-0 5
Not Joint 4-0 7
Joint 3-0 10
Scalp 4-0 7
Mucous Membrane absorbable (vicryl) N/A
N.B.  Patients on steroid therapy may need sutures in for longer periods of time

Bruises

Bruises
  • Tender swelling (hematoma) following blunt trauma
  • Is patient on anticoagulants? do they have a coagulopathy (e.g. liver disease)?

Abrasions

Abrasions
  • Partial to full thickness break in skin
  • Management:
    • Clean thoroughly, +/- local anesthetic, with brush to prevent foreign body impregnation (tattooing)
    • Antiseptic ointment (Polysporin or Vaseline) for 7 days for facial and complex abrasions
    • Tetanus prophylaxis - see Table 9 above

Laceration

Lacerations

  • Consider every structure deep to a laceration injured until proven otherwise
  • In hand injury patient, include following in history: handedness, occupation, mechanism of injury, previous history of injury
  • Physical exam
    • Think about underlying anatomy
    • Examine tendon function actively against resistance and neurovascular status distally
    • Clean and explore under local anesthetic; look for partial tendon injuries
    • X-ray wounds if a foreign body is suspected (e.g. shattered glass) and not found when exploring wound (remember: not all foreign bodies are radiopaque), or if suspect intra-articular involvement
  • Management
    • disinfect skin/use sterile techniques
    • irrigate copiously with normal saline
    • analgesia +/- anesthesia
  • Maximum dose of lidocaine:
    • 7 mg/kg with epinephrine
    • 5 mg/kg without epinephrine
  • In children, topical anesthetics such as LET (lidocaine, epinephrine and tetracaine) and in selected cases a short-acting benzodiazepine (midazolam or other agents) for sedation and amnesia are useful
  • Secure hemostasis
  • Evacuate hematomas, debride non-viable tissue, remove hair and remove foreign bodies
  • +/- prophylactic antibiotics
  • Suture unless delayed presentation, a puncture wound, or mammalian bite
  • Take into account patient and wound factors when considering suturing
  • Advise patient when to have sutures removed
Clinical Pearl
Alternatives to Sutures
- Tissue glue
- Steri-strips
- Staples

Mnemonic
Where not to use local anesthetic with epinephrine:
Ears, Nose, Fingers, Toes and Hose (Penis)

Digital Block

Figure 10. Digital Block - Local Anesthesia of Digits

Cellulitis

Cellulitis
  • localized infection of the dermis
  • bacterial (S. aureus, GAS, H. influenzae, rarely pseudomonas, MRSA) infection of skin and subcutaneous tissues
  • look for - rubor, calor, dolor, tumor (erythema, warmth, pain, swelling)
  • have high index of suspicion in patients who are immunocompromised (e.g. HIV, DM), vasculopaths, IV drug users
  • treat with immobilization and elevation of infected area, antibiotics, analgesics, and close follow-up
  • antibiotics for common cellulitis: cefazolin IV then cephalexin PO (alt: clindamycin PO, vancomycin IV then linezolid PO); consider MRSA

Definition

  • Non-suppurative infection of skin and subcutaneous tissues

Etiology

  • Skin flora most common organisms: S. aureus, b-hemolytic Streptococcus
  • Immunocompromised: Gram negative rods and fungi

Clinical Pearl
Cellulitis vs. Erysipelas
Cellulitis: indistinct borders
Erysipelas: sharp borders

Clinical Features
  • Source of infection
    • Trauma, recent surgery
    • PVD, diabetes - cracked skin in feet/toes
    • Foreign bodies (IV, orthopaedic pins)
  • Systemic symptoms:   fever, chills, malaise
  • Pain, tenderness, edema, erythema with poorly defined margins, tender regional lymphadenopathy
  • Can lead to ascending lymphangitis (visible red streaking in skin proximal to area of cellulitis)

Investigations

  • CBC, blood cultures x 2
  • Culture and Gram stain wound/aspirate from wound
  • Plain radiographs 
    • r/o bone invasion (osteomyelitis)
    • If crepitus present, may see gas in soft tissues (requires surgical correction)

Treatment

  • Antibiotics: 
    • First line :
      • Bactrim DS PO bid x 10 d (#20)
      • Keflex 500mg PO q6h x 10 d (#40)
      • Clindamycin 300-450mg PO q6h x 10 d (#40)
      • Doxycycline 100mg PO bid x 10 d (#20)
    • In-Patient: Vancomycin 15mg/kg IV q12h + Unasyn 1.5g IV q6h
    • To cover Pseudomonas: Ceftazidime 1-2g IV q8h x 10-14 days
  • Outline area of erythema to monitor success of treatment
Clinical Pearl
Differential Diagnosis of cellulitis
  • Necrotizing Fasciitis
  • Gas gangrene
  • Cutaneous anthrax
  • Vaccinia vaccination
  • Insect bite (hypersensitivity)
  • Acute gout
  • DVT
  • Fixed drug reaction
  • Kawasaki
  • Pyoderma gangrenosum
 

Abscess

Abscess
  • May be associated with a retained foreign body
  • Look for warm, swollen, painful, erythematous fluctuant masses
  • Ensure absence of systemic symptoms and presence of subcutaneous air in simple abscesses
  • Anesthetize locally
  • Treat with incision and drainage +/- antibiotics (Keflex, Bactrim, Clindamycin) - apply warm compress, give analgesics

Clinical Pearl
Which Abscesses Need Antibiotics?
- Evidence of systemic illness (e.g. cellulitis)
- Immunocompromised patient
- Patient at risk for Endocarditis

Clinical Pearl
Early wound irrigation and debridement are the most important factors in decreasing infection.