CHAPTER 1

Emergency Wound Care:

An Overview
Key Practice Points
nn The average laceration cared for by emergency caregivers is 1 to 3 cm in

length, with 13% of lacerations considered significantly contaminated.

most common complication of wound care is infection, occurring
in 3.5% to 6.3% of lacerations.
nn The most important step for reducing infection in wound care is wound
irrigation.
nn All wounds form scars and take months to reach their final appearance.
nn 95% of glass in wounds is radio-opaque, and radiographs are
recommended.
nn The understanding of local practice when caring for wounds, such as
the use of prophylactic antibiotics for wound care, is important.

nn The

Superficial wounds, including lacerations, bites, small burns, and punctures, are among
the most common problems faced by emergency physicians and other providers of
urgent and primary care. Each year in emergency departments (EDs) in the UnitedStates,
12.2million patients with wounds are managed.1 The most frequently performed procedure in the ED, other than intravenous-line (IV-line) insertion, is wound care.2
Of 1000 patients whose clinical findings were entered into a wound registry, 74%
of the patients were male, with an average age of 23.3 The average laceration was 1 to
3 cm in length, and 13% of lacerations were considered significantly contaminated.
Most wounds (51%) occurred on the face and scalp, followed by wounds on the upper
(34%) and lower (13%) extremities. The remaining wounds occurred on various sites of
the truncal areas and proximal extremities.
The most common complication of wound care is infection. Approximately 3.5% to
6.3% of laceration wounds become infected in adults treated in the ED.4-6 Infection is
more likely to occur with bite wounds, in lower extremity locations, and when foreign
material is retained in the wound. The rate of infection in children is only 1.2% for lacerations of all types.7

GOALS OF WOUND CLOSURE

Because wounding is an uncontrolled event and there are biologic limitations to healing, the wounded skin and related structures cannot be perfectly restored. Each step of
wound care serves to achieve the best possible outcome with the fewest problems.
Hemostasis: All bleeding from the wound except minor oozing should be controlled,
usually with gentle, continuous pressure, before wound closure.
Anesthesia: Effective local anesthesia before wound cleansing allows the caregiver to
clean the wound thoroughly and to close it without fear of causing unnecessary pain.

1
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CHAPTER 1 Emergency Wound Care: An Overview

 ound irrigation: Irrigation is the most important step in reducing bacterial contamiW
nation and the potential for wound infection.
Wound exploration: Wounds caused by glass or at risk for deep structure damage
should be explored. Radiographs and functional testing do not always identify foreign bodies or injured tendons.
Removal of devitalized and contaminated tissue: Visibly devitalized and contaminated tissue that could not be removed through wound cleansing and irrigation needs to be
completely but judiciously dbrided.
Tissue preservation: At the time of ED or primary closure, tissue excision should be
resisted. It is best to tack down what remains of viable tissue, especially in complicated wounds. Because of the natural contraction of wounds, cosmetic revisions done
later can be accomplished successfully if sufficient tissue remains. Unnecessary tissue
excision can lead to a permanent, uncorrectable, and unsightly scar.
Closure tension: When laceration edges are being brought together, they should just
barely touch. Excessive wound constriction when tying knots strangulates the
tissue, leading to a poor outcome. If necessary, tension-reducing techniques, such as
the placement of deep sutures and undermining, can be applied.
Deep sutures: Because all sutures act as foreign bodies, as few deep sutures as possible
are to be placed in any wound.
Tissue handling: Rough handling of tissues, particularly when using forceps, can cause
tissue necrosis and increase the chance of wound infection and scarring.
Wound infection: Antibiotics are no substitute for wound preparation and irrigation.
If the decision is made to treat the patient with antibiotics, the initial dose is most
effective when administered intravenously as soon as possible after wounding.
Dressings: Wounds heal best in a moist environment provided by a properly applied
wound dressing.
Follow-up: Well-understood verbal and written wound care instructions and timely
return for a short follow-up inspection or suture removal at the proper interval are
essential to complete care.

PATIENT EXPECTATIONS
One of the most important aspects of wound care is understanding and managing the
patients reaction to a wound. Patients often have many preconceptions about wound
care and expectations about the outcome, which are often unrealistic. Patients sometimes believe that wounds can be repaired without scar formation. All wounds leave a
scar, which is a fact that has to be conveyed to all patients. Scar formation and wound
healing will be more thoroughly discussed in Chapters 4 and 22.
Another patient misconception is the time it takes for wounds to heal. Ironically,
when the sutures are removed, that is the weakest point in healing (see Chapter 4,
Fig. 4-2). Sutures are removed when there is enough holding strength to keep the
wound edges together and to prevent increased scarring that can be caused by leaving
sutures in the wound too long. If there is concern that the wound might open after
suture removal, Steri-Strips can be applied to give the wound time to become stronger.
Final scar appearance may not be evident for several months because of the biologic
complexity of wound healing.

RISKS OF WOUND CARE

A fact of life for patient care in the United States is the risk of liability. Wounds cared
for in EDs are often considered minor. Yet in a study of closed malpractice claims
against emergency physicians in Massachusetts, wounds were the most common source
of those claims.8 Of the 109 claims, 32% involved retained foreign bodies, and another

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CHAPTER 1 Emergency Wound Care: An Overview

34% were caused by allegedly undiagnosed injuries to a tendon or a nerve. The four
leading causes of mistakes in emergency-care malpractice cases are failure to order tests
(such as radiographs for retained glass), inadequate history and physical exam (tendon
or nerve injuries), misinterpretation of tests, and failure to obtain a consultation (often
necessary in hand wounds).9
The most commonly retained foreign body is glass.10 Patients who receive injuries
from glass cannot report accurately whether the glass remains in the wound.11 Radiographs are recommended for most of these wounds. Under study conditions, more than
95% of glass, of all types, as small as 0.5 mm, can be visualized by radiography.12 In the
clinical setting, however, fragments can be missed. In addition to radiographs, wound
exploration is recommended in wounds potentially bearing glass (see Chapter 16).
Tendon injuries of the hand are not always apparent. The patient can appear to have
normal hand function but have a laceration of one or more tendons. The most commonly missed injury is to the extensor tendon.13 Extensor tendons are cross-linked at
the level of the metacarpals. An injury to a tendon proximal to the adjacent tendon
cross-link can give the appearance of normal extensor function. Tendons also can be
partially severed and retain function. A good understanding of the complex functional
anatomy of the hand and a thorough testing of each tendon reveal most complete injuries. Only exploration can define accurately the extent of partial injuries, however.
If a claim is made against an emergency physician, the care of the patient is most
likely to be compared with what a specialist would have done in a similar circumstance.
In other words, physicians who do not practice emergency medicine often define the
standard of care. An example of this dilemma is an infected wound. If an infection
results from a sutured laceration, specialists often opine that prophylactic antibiotics should have been administered. Currently, there are no solid, evidenced-based data
showing that antibiotics prevent traumatic skin-wound infections. Because antibiotics
are administered frequently without firm science, however, it is important for emergency physicians to follow local practice or relevant guidelines that address these circumstances.

References

1. McCaig LF, Ly N: National hospital ambulatory medical care survey: 2000 emergency department
summary, Adv Data 22:137, 2002.
2. Pitts SR, Niska RW, Xu J, Butt CW: National hospital ambulatory medical survey: 2006 emergency
department survey, Natl Health Stat Report 6:138, 2008.
3. Hollander JE, Singer AJ, Valentine S, Henry MC: Wound registry: development and validation, Ann Emerg
Med 25:675685, 1995.
4. Gosnold JK: Infection rate of sutured wounds, Practitioner 218:584591, 1977.
5. Rutherford WH, Spence R: Infection in wounds sutured in the accident and emergency department, Ann
Emerg Med 9:350352, 1980.
6. Thirlby RC, Blair AJ, Thal ER: The value of prophylactic antibiotics for simple lacerations, Surg Gynecol
Obstet 156:212216, 1983.
7. Baker MD, Lanuti M: The management and outcome of lacerations in urban children, Ann Emerg Med
19:10011005, 1990.
8. Karcz A, Korn R, Burke MC, etal: Malpractice claims against physicians in Massachusetts: 1975-1993, Am
J Emerg Med 14:341345, 1996.
9. Kachalia A, Gandhi TK, Puopolo AL, etal: Missed and delayed diagnoses in the emergency department: a
study of closed malpractice claims from 4 liability insurers, Ann Emerg Med 49:196205, 2007.
10. Kaiser CW, Slowick T, Spurling KP, etal: Retained foreign bodies, J Trauma 43:107111, 1997.
11. Montano JB, Steele MT, Watson WR: Foreign body retention in glass-caused wounds, Ann Emerg Med
21:13651368, 1992.
12. Tanberg D: Glass in the hand and foot, JAMA 248:18721874, 1982.
13. Guly HR: Missed tendon injuries, Arch Emerg Med 8:8791, 1991.

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