injuries poisoning
Lacerations
Treatment of Lacerations
Treating lacerations involves Cleansing and local anesthesia (sequence can vary) Exploration Debridement Closure Tissue should be handled as gently as possible. Both the wound and the surrounding skin are cleansed. Subepidermal tissue in the wound is relatively delicate and should not be exposed to harsh substances (eg, full-strength povidone iodine,chlorhexidine,hydrogen peroxide) and vigorous scrubbing. Removing hair from laceration edges is not necessary for wound hygiene but can make markedly hairy areas (eg, scalp) easier to work on. If necessary, hair is removed with electric clippers or scissors, not shaving; razors create microtrauma, allowing skin pathogens to enter and increasing risk of infection. Hair is clipped before wound irrigation so that any clipped hair entering the wound is removed. Eyebrows are not trimmed because the hair-skin border is needed for proper alignment of wound edges. Traditional teaching is that the eyebrow may never grow back or grow back abnormally. However, evidence to support or refute this is lacking. Although wound cleansing is not particularly painful, local anesthesia is usually administered first, except for heavily contaminated wounds; these wounds are best initially cleansed with running tap water and mild soap before a local anesthetic is administered. Tap water is clean and free of typical wound pathogens, and, used in this manner, does not seem to increase risk of infection. Wounds are then cleansed by a high-velocity stream of liquid and sometimes scrubbed with a fine-pore sponge; brushes and rough materials are avoided. An appropriate irrigation stream can be created using a 20-, 35-, or 50-mL syringe with a 20-gauge needle or IV catheter; commercially available devices incorporating a splash guard help limit splatter. Sterile 0.9% saline is an effective irrigant; specialized surfactant irrigants are costly and of doubtful additional benefit. If bacterial contamination is of particular concern (eg, bites, old wounds, organic debris), povidone iodine solution diluted 1:10 in 0.9% saline may be beneficial and is not harmful to tissues at this concentration. The volume necessary varies. Irrigation continues until visible contamination is removed and at least 100 to 300 mL has been applied (more for large wounds). Painting the skin with a mixture ofchlorhexidineand alcohol before suturing may reduce skin flora, but the substance should not be introduced into the wound. Generally, injectable local anesthetics are used. Topical anesthetics are beneficial in certain cases, especially for wounds of the face and scalp and when topical skin adhesives are used to close wounds. Common injectable agents arelidocaine0.5%, 1%, and 2%, andbupivacaine0.25% and 0.5%, both from the amide group of local anesthetics; the ester group includes procaine,tetracaine, andbenzocaine.Lidocaineis most commonly used.Bupivacainehas a slightly slower onset (several minutes vs almost immediate) and a significantly longer duration (2 to 4 hours vs 30 to 60 minutes). Duration of action of both can be prolonged by addingepinephrine1:100,000, a vasoconstrictor. Because vasoconstriction may impair wound vascularity (and thus defenses),epinephrineis mostly used for wounds in highly vascular areas (eg, face, scalp). Although traditional teaching has been to avoid usingepinephrinein distal parts (eg, nose, ears, fingers, penis) to prevent tissue ischemia, complications from use on distal parts are rare, and such use is now considered safe.Epinephrinecan be particularly helpful in achieving hemostasis in wounds that are bleeding heavily. The maximum dose oflidocaineis 3 to 5 mg/kg (1% solution=1 g/100 mL=10 mg/mL), and that ofbupivacaineis 2.5 mg/kg. Addition ofepinephrineincreases the allowable dose oflidocaineto 7 mg/kg, and ofbupivacaineto 3.5 mg/kg. Adverse reactions to local anesthetics include allergic reactions ( Urticaria and, occasionally, Techniques recommended to minimize the pain of injection include the following: Using a small needle (a 27-gauge needle is best, and a 25-gauge is acceptable; a 30-gauge may be too flimsy) Giving the injection slowly Giving the injection into the subcutaneous plane instead of intradermally Bufferinglidocainewith 8.4%sodium bicarbonate, raising the pH from 4.2 to 7.4 (for example, at ratios oflidocainetosodium bicarbonatethat can range from 3:1 to 9:1) (NOTE: Buffering decreases the shelf life of multidoselidocainevials, and buffering is less effective forbupivacaine.) Warming the anesthetic solution to body temperature Pretreating the wound with topical anesthetic Brief cooling of wound edges with ice Regional nerve blocksare sometimes preferred to wound injection. Nerve blocks cause less distortion of wound edges by injected anesthetic; this decreased distortion is important when alignment of wound edges must be particularly precise (eg, infraorbital nerve block for lacerations through the vermilion border of the lip) or when wound injection would be difficult because the space for injection is small (eg, digital nerve block for finger lacerations). Also, large areas can be anesthetized without using toxic doses of anesthetic. Slight disadvantages of nerve blocks are slower onset of anesthesia and sometimes100% effectiveness with the first injection. © Elsevier Inc. All Rights Reserved. This video is for personal informational use. Users are prohibited from copying, reproducing, licensing, subscribing, selling, leasing or distributing this video. © Elsevier Inc. All Rights Reserved. This video is for personal informational use. Users are prohibited from copying, reproducing, licensing, subscribing, selling, leasing or distributing this video. Procedure demonstrated by Scott Solow, DDS, Pediatric Dentistry and Orthodontics. Filmed on location at Pediatric Dentistry and Orthodontics Medical Arts Building, Philadelphia, PA. © Elsevier Inc. All Rights Reserved. This video is for personal informational use. Users are prohibited from copying, reproducing, licensing, subscribing, selling, leasing or distributing this video. © Elsevier Inc. All Rights Reserved. This video is for personal informational use. Users are prohibited from copying, reproducing, licensing, subscribing, selling, leasing or distributing this video. © Elsevier Inc. All Rights Reserved. This video is for personal informational use. Users are prohibited from copying, reproducing, licensing, subscribing, selling, leasing or distributing this video. Use oftopical anesthesiamakes injection unnecessary and is completely painless—factors particularly desirable in children and fearful adults. The most common solution is LET, which consists oflidocaine2 to 4%,epinephrine1:1000 or 1:2000, andtetracaine0.5 to 2%. A cotton dental pledget (or cotton ball) the length of the wound soaked in several milliliters of the solution and placed within the wound for 30 minutes usually provides adequate anesthesia. If anesthesia is incomplete after application of a topical anesthetic, supplementary local anesthetic can be injected through the partially anesthetized wound edges, usually with minimal pain. The full extent of the wound is explored to look for foreign material and possible tendon injury. Foreign material may also often be discerned by palpating gently with the tip of a blunt forceps, feeling for a discrete object and listening for a click characteristic of glass or metal foreign bodies. Occasionally, contaminated puncture wounds (eg, human bite wounds near the metacarpophalangeal joint) must be extended so that they can be adequately explored and cleansed. Deep wounds near a major artery should be explored in the operating room by a surgeon. Laceration debridement uses a scalpel, scissors, or both to remove dead tissue, devitalized tissue (eg, tissue with a narrow base and no viable blood supply), and sometimes firmly adherent wound contaminants (eg, grease, paint). Macerated or ragged wound edges are excised; usually 1 to 2 mm is sufficient. Otherwise, debridement is not used to convert irregular wounds into straight lines. Sharply beveled wound edges are sometimes trimmed so that they are perpendicular. Decision to close a wound depends on the wound’s location, age, cause, and degree of contamination and on patient risk factors. Most wounds can be closed immediately (primary closure). Primary closure is usually appropriate for uninfected and relatively uncontaminated wounds<6 to 8 hours old (<12 to 24 hours for face and scalp wounds). Many other wounds can be closed after several days (delayed primary closure). Delayed primary closure is appropriate for wounds too old for primary closure, particularly if signs of infection have begun to appear, and for wounds of any age with significant contamination, particularly if organic debris is involved. The threshold for using delayed primary closure is lowered for patients with risk factors for poor healing. At initial presentation, anesthesia, exploration, and debridement are done at least as thoroughly as for other wounds, but the wound is loosely packed with moist saline-soaked gauze. The dressing is changed at least daily and evaluated for closure after 3 to 5 days. If there are no signs of infection, the laceration is closed by standard techniques. Loosely closing such wounds initially may be ineffective and inappropriate because the wound edges nonetheless typically seal shut within 12 to 24 hours. Some wounds should not be closed. These wounds include the following: Wound care to hands or feet Puncture wounds High-velocity missile wounds Traditionally, sutures have been used for laceration repair, but metal staples, adhesive strips, and liquid topical skin adhesives are now used for certain wounds, mainly linear lacerations subject to only small amounts of tension. Whatever the material used, preliminary wound care is the same; a common error is to do cursory exploration and no debridement because a noninvasive closure not requiring local anesthesia is planned. Staplesare quick and easy to apply and, because there is minimal foreign material in the skin, are less likely to cause infection than sutures. However, they are suited mainly for straight, smooth cuts with perpendicular edges in areas of low skin tension. Improper wound edge apposition (sometimes causing wound edges to overlap) is the most common error. Topical skin adhesivesusually contain octyl cyanoacrylate, butyl cyanoacrylate, or both. They harden within a minute; are strong, nontoxic, and waterproof; form a microbial barrier; and have some antibacterial properties. However, adhesive should not be allowed into the wound. Infections are very unlikely, and cosmetic results are generally good. Adhesive is best for simple, regular lacerations; it should not be used for wounds under tension unless tension is relieved with deep dermal sutures, immobilization, or both. In wounds requiring debridement, deep dermal suturing, or exploration under local anesthesia, the advantages of decreased pain and time are minimized. However, patients do not require follow-up for suture or staple removal. With long lacerations, skin edges can be held together by a 2nd person or with skin tapes while the adhesive is applied. Generally, only one layer is applied as recommended by the manufacturer. The adhesive sloughs spontaneously in about a week. Excess or inadvertently applied adhesive can be removed with any petrolatum-based ointment or, in areas away from the eyes or open wounds, acetone. Adhesive stripsare probably the quickest repair method and have a very low infection rate. They are useful for wounds not subject to tension. Use on lax tissue (eg, dorsum of hand) is difficult because wound edges tend to invert. Adhesive strips cannot be used on hairy areas. Adhesive strips are particularly advantageous for lacerations in an extremity that is to be casted (thus blocking appropriate suture removal). Adhesive strips can also be used to reinforce wounds after suture or staple removal. Skin must be dry before application. Many clinicians apply tincture of benzoin to boost adhesion. Improper application may result in blister formation. Adhesive strips may be removed by the patient or eventually will fall off on their own. Suturesare the best choice for Irregular, heavily bleeding, or complex lacerations Areas of loose skin Areas under tension Wounds requiring deep dermal closure Because sutures can serve as an entry site for bacteria and there is a significant amount of foreign material under the skin, they have the highest rate of infection among materials used to close lacerations. Suture materials can be monofilament or braided and absorbable or nonabsorbable. Characteristics and uses vary (see table); generally, absorbable material is used for deep dermal sutures, and nonabsorbable material is used for percutaneous ones. Outcomes using rapidly absorbing absorbable sutures are comparable to those using nonabsorbable sutures. Rapidly absorbing absorbable sutures should be considered when suture removal is undesirable, such as in children and nonadherent patients. Braided material generally has higher tissue reactivity and thus poses a slightly higher risk of infection than does monofilament but is soft and easy to handle and has good knot security. Absorbable sutures containing antiseptic agents such as triclosan are available and may help reduce infection. General goals include the following: Closely approximating skin margins Everting wound edges Eliminating dead space Minimizing tension on the wound and of individual sutures Minimizing the amount of foreign material The relative importance of minimizing wound tension and minimizing the amount of material buried under the skin (eg, deep dermal sutures) vary by wound location. For example, in facial wounds, cosmetic result is very important and, because of the excellent vascular supply, infection risk is low. Thus, for gaping wounds, deep dermal sutures, which decrease wound tension and improve cosmetic result, are desired; infection risk is low even if they are used. In areas where vascular supply is poor or cosmetic result is less important, deep dermal sutures are less desirable. Sutures may be placed and tied individually (interrupted sutures) or be continuous (running suture). They may be completely buried under the skin (subcuticular or deep dermal sutures) or enter and exit the skin to be tied externally (percutaneous sutures). The suture begins and ends at the bottom of the wound so that the knot is deeply buried. If the wound is gaping, deep dermal suturing tends to be used initially (see figure); the resultant narrow epidermal gap is then closed by percutaneous sutures. For wounds on the face, any gaping>5 to 10 mm may benefit from deep dermal suturing (not used on nose and eyelids); in other body areas, a wider gap is acceptable. Interrupted sutures using size 4-0 or 5-0 (smaller numbers indicate thicker material with greater tensile strength) absorbable material (eg, polyglactic acid, poliglecaprone 25) are most common. They are placed with the knot at the bottom of the wound to avoid a palpable lump and must not be too tight. A running subcuticular suture is sometimes used, especially for cosmetic repairs. The suture begins and ends equidistant from the wound margins. Points A and B are at the same depth. The suture is farther from the wound edge when the wound is deep. The skin edges should be everted by making the width of the bite greater at the deepest part of the wound than at the surface. Epidermal closure is typically with simple, interrupted sutures (see figure Simple Cutaneous Suture ) of nonabsorbable monofilament (eg, nylon, polypropylene). Suture size depends on where the wound is located. In areas over large joints and the scalp, size 3-0 or 4-0 sutures are used. For facial wounds, size 5-0 or 6-0 sutures are used. For wounds in the hand, size 5-0 sutures are used. In most other areas, size 4-0 or 5-0 sutures are used. Suture size can vary slightly depending on how much static and dynamic tension is predicted (eg, for facial lacerations subject to frequent movement or high tension, size 5-0 sutures may be used). Sutures are placed about as deep as they are wide and are spaced as far apart as the distance from the needle entry point to wound edge (see figure). Small bites (suture typically inserted 1 to 3 mm from the wound edge) are used for repairs in areas where cosmetic results are of particular concern and when tissues are thin. For other repairs, wider bites are used, varying with the tissue thickness. Wound edges can be everted by making the width of the bite greater at the deepest part of the wound than at the surface. Eversion is more easily obtained when the hand is fully pronated and the skin is entered with the needle at a 90° angle and angled slightly away from the skin edge. Spacing between sutures is typically equal to the distance from needle entry to wound margin. Sutures should enter and exit at an equal distance from the wound margin. A vertical mattress suture (see figure) is sometimes used instead of a layered closure, provided skin tension is not marked; it also helps ensure proper edge eversion in loose tissue. A running suture (see figure) is quicker to place than interrupted sutures and can be used when wound edges are well aligned. The first pass of the needle is the same as a large simple suture, but instead of tying off, another smaller bite is taken back across the wound to end on the starting side. Both ends are pulled up to closely align (approximate) the wound edges. Points A and B must be at the same depth, as must points C and D; this placement results in correct vertical alignment. This suture begins with a simple suture at one end of the wound. The non-needle end is cut, and then suturing continues; the bite under the skin is perpendicular to the wound, and the crossover is at about a 65° angle. Sutures should be evenly spaced and are snugged up as they are done, except for the last one, which is left as a loop; this loop is tied to the needle end. In all cases, epidermal closure must precisely realign edges horizontally using natural skin landmarks (eg, folds, creases, lip margins) when available. Vertical alignment is equally important to avoid a step-off deformity. Excess tension after closure is evidenced by indenting of the skin or a sausage link appearance. Such a repair should be redone, adding deep dermal sutures, additional percutaneous sutures, or both as needed. Adjustments to suture technique are needed to achieve optimal alignment when wound edges are beveled. For example, edges may be debrided or suture bite size may differ from one side of the wound to the other. Tetanus immunizationis given if necessary (see table). Topical antibiotic ointment(eg,bacitracin,bacitracin/neomycin/polymyxin) is applied daily; it can reduce risk of infection and help maintain a moist wound environment that optimizes healing. However, ointment is not used over tissue adhesives or adhesive strips. Prophylactic systemic Antimicrobials None Bite wounds on the extremities Human and Mammal Bites None Wounds involving tendons, bones, or joints Possibly intraoral lacerations Some heavily contaminated wounds If deemed necessary, antibiotics are given as early as possible; the first dose may be given parenterally. Wounds are immobilizedbecause excess movement of the affected area may interfere with healing. Wounds near joints should be immobilized with splints. Bulky dressings are used to immobilize fingers and hands. Wounds should be elevated, above heart level when feasible, for the first 48 hours after suturing. A sling may help maintain some degree of elevation of an upper extremity wound. Patients with distal lower extremity lacerations (other than minor) should probably stay off their feet for several days (eg, by using crutches); elevation of the foot and restrictions on walking probably result in better healing. Wound careis meticulous. The wound is kept clean and dry; dressings that are nonadherent and impermeable to bacteria are usually applied. Antibiotic ointment is applied daily until the wound closure device is removed. A reliable patient may inspect minor, clean lacerations, but early physician examination is preferable for higher risk wounds and wounds in unreliable patients. After 12 hours, well-healing wounds can be cleansed gently of residual secretions with water, half-strengthhydrogen peroxide, or soap and water. Brief wetting in the shower is safe, but prolonged soaking should be avoided. 12 hours after closure is often the earliest manifestation, and initial signs are redness more than about 0.5 cm from the wound edge, swelling, tenderness, and warmth. Later signs may include fever, purulent drainage, and ascending Lymphangitis . Systemic antibiotics effective against skin flora are begun; a 1st-generation cephalosporin (eg, Closure material(except for tissue adhesive) is removed after various intervals depending on location. For facial lacerations, sutures are removed in 3 to 5 days to prevent cross-hatching and visible needle entrance marks; some clinicians apply adhesive strips to bolster the wound for a few more days. Sutures and staples on the torso and upper extremities are removed in 7 to 10 days. Sutures and staples on hands and fingers, the extensor surface of the elbow, knee, and anywhere below the knee should remain for 10 to 12 days. 