Traumatic wounds are regularly encountered in the emergency department. It is important to document important historical information such as the mechanism, timing, and location of injury, and the degree of contamination. Associated symptoms of pain, swelling, paresthesias, and loss of function should be identified. Ascertain factors that affect wound healing, such as the patient's age, location of injury, medications, chronic medical conditions (eg, diabetes, chronic renal failure, or immunosuppression), and previous scar formation (keloid). Patients with the sensation of a foreign body are much more likely to have retained a foreign body. Patient characteristics of handedness, occupation, tetanus status, and allergies (eg, to analgesics, anesthetics, antibiotics, or latex) should be documented. 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 the time, mechanism of injury, and its location because these factors play a role in the potential for infection. Shear, compressive, or tensile forces cause acute traumatic wounds. 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 underlying bone. These high-energy forces produce stellate lacerations. Tension forces produce flap-type lacerations. These wounds typically have surrounding devitalized tissue and result in a wound much more susceptible to infection than those caused by shear forces.
Assessment of a wound's potential for infection is vital. Predictive factors for infection include location, depth, characteristics, contamination, and patient age. The risk of infection relates to the interaction of bacterial contamination, time to wound closure, and blood supply. The density of bacteria is quite low over the trunk and proximal arms and legs. Moist areas such as the axilla, perineum, and exposed hands and feet have a higher degree of colonization.
Wounds of the oral cavity are heavily contaminated with facultative and anaerobic organisms. 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 despite determined therapy. Over the first 24 hours, the longer the time from injury to wound closure, the greater the risk of infection. Wounds in highly vascular areas such as the face and scalp are less likely to become infected.
Wound examination is greatly facilitated by a cooperative patient, good positioning, optimal lighting, and little or no bleeding. Universal precautions should be used during evaluation. A thorough and compulsory examination will minimize the risk of missed foreign bodies, tendon, and nerve injuries, a common cause of litigation.
Documentation of a wound should include the location, size, shape, margins, and depth. Pay particular attention to sensory, motor, tendon, vascular compromise, and injuries to specialized structures. Blood pressure differences between injured and noninjured extremities will help identify significant arterial injuries. ...