Clinical aspects The principles of resuscitation of a patient with gunshot injury are ident ical to those for any major trauma case. Speci \201 c aspects are: \200 Consider staff s afety: involve police and check the patient for weapons. \200 The magnitude of the extern al wounds may bear little relationship to the severity of internal injury. Remove the patie nt \200\231s clothes (police evidence) and examine the entire body for entrance/exit wounds that are often missed in hairy areas (eg scalp, axillae, and perineum). Patients are often young and \201 t: signs of hypovolaemia may be delayed. \200 Chest i njuries are commonly associated with pneumothorax ( b p.334). PEA cardiac arrest should pro mpt rapid exclusion of tension immediate thoracotomy to relieve cardiac pneumothorax then t amponade ( b p.343). Abdominal wounds are associated with a high incidence of internal injury and require laparotomy and antibiotic cover. Gunshot wounds are prone to anaerobic infection (especially tetanus and gas gangrene): clot hing/fragments spread widely through tissues distant from the wound track. Extensive surgic al debridement (wide excision/fasciotomy) is often required to remove devitalized tissue an d foreign material. All high velocity injuries need delayed primary closure with grafting o r suture at 3 \200\2235 days. Ensure tetanus cover and give prophylactic antibiotics. \200 X-ray (AP + lateral) one bod y region above and one body region below any wound, as well as the region involved, to look for metallic FBs. 389 BLAST INJURIES Blast injuries Blast injuries may be due to explosions involving domestic gas, industrial s ites (eg mines/mills), or bombs. Often several mechanisms co-exist to cause injury. Blast w ave (primary blast injury) This is an extremely short-lived pressure wave (lasting a few mi lliseconds only) which expands outwards from the explosive focus. It is produced by intense compression of air at the interface of the rapidly expanding hot gasses. The effects can b e dramatically aggravated and reinforced by re \202 ection from solid surfaces, such as bu ildings. Blast wave injuries are caused by 3 mechanisms: \200 Disruption at air/tissue in terfaces (especially lungs and ears, producing blast lung and tympanic membrane rupture, respectively). Shearing injuries at tissue/tissue interfaces causing subserous and submucosal hemorrhage. Implosion of gas- \201 lled organs leading to perforation of the GI tract and cerebral or coronary air embolism. Blast winds These are fast moving columns of air that follow the initial blast wave. Their destructive force can be immense, leading to traumatic amputation or even complete dismembe rment. Blast winds also carry debris (masonry, glass, etc.), which act as secondary missile s causing fragmentation injuries. Fragmentation injuries Objects from a bomb (eg nails, cas ing, nuts, and bolts) or \202 ying debris (masonry, wood, glass) cause lacerations or pen etrating injuries. This is classi \201 ed as secondary blast injury . Flash burns These ar e usually super \201 cial, affecting exposed skin in those close to the explosion. Smoke i nhalation may also occur. Tertiary blast injuries result from individuals being thrown by t he blast wind, often causing severe multiple injuries. Quaternary blast injuries include al l explosion related injuries or illnesses not due to primary, secondary, or tertiary mechan isms listed above. Psychological The psychological effects of blast injury are often severe , comprising acute fear, anxiety, and the potential for chronic sequelae. General aspects of treatment The principles of blast injury treatment are identical to thos e for patients with other causes of major trauma ( b p.320). Clinical features in blast inj uries may be delayed, both in terms of onset and development of clinical signs. This partic ularly relates to lung and intra- abdominal complications; therefore, observe all patients for at least 48hr. Search for pneumothorax (may be tension), respiratory failure/ARDS, peri tonitis, abnormal neurological signs (suggesting air embolism), eardrum perforation, anosmi a (direct olfactory nerve damage). Note that ventilation of patients with blast injuries is a highly specialized area, with potential risks of producing tension pneumothoraces and ai r embolism. Other aspects For forensic reasons, ensure that all the patient \200\231s clothes, belongin gs, and any missile fragments are carefully retained, bagged, labeled, and kept secure unti l given to police of \201 cers. 390 CHAPTER 8 Major trauma Burns: assessment Types of burns \200 Thermal. \200 Chemical. \200 Electrical ( b p.2 66). \200 Radiation ( b p.268). History Determination of the circumstances resulting in the patient being burned is essenti al to appreciate the nature of the insult and potential associated risks. Do not, however, delay resuscitation in an attempt to obtain a full history. Consider the following question s: \200 Was there an explosion? (risk of blast injuries). \200 Was the \201 re in an enclosed space? (CO poisoning, smoke inhalation). \200 What was the burning material? (bu rning plastics release cyanide). \200 When was the patient removed from the \201 re? \200 How long was the patient exposed to \201 re and smoke? \200 Was there a history o f loss of consciousness? \200 Did the patient fall or jump to escape the \201 re? (look for other injuries). \200 What is the patient \200\231s past medical history and tetanus status? Initial assessment This proceeds with resuscitation. Check : Airway, Breathing and Circulat ion. Particular problems associated with burns are: \200 Airway burns : suggested by hoar seness, stridor, dysphagia, facial and mouth burns, singeing of nasal hair, soot in nostrils, or on palate Spinal injury : particularly seen with blast injuries and in those who have jumped from buildings to escape \201 re Breathing problems : contracting full thickness circumferential burns ( \200\230eschar \200\231) of the chest wall may restrict chest movement Circulatory problems : hypovolaemic shock is a feature of severe burns and may also result from other associated injuries. Assessing extent Estimation of the percentage of body surface area burnt is dif \201 cult for non-experts. Use Lund and Browder charts appropriate for the age of the patient (see Ta ble 8.5 , Fig. 8.16 ). The palmar surface of the patient \200\231s palm (not including the \201 ngers) represents \211\210 0.75 % body surface area. Assessing depth Burn depth varies with the temperature and duration of heat applied. Super \201 cial ( \201 rst and second degree) burns range from minor erythema ( \201 rst degree) through painful erythema with blistering, to deep partial thickness (second degree ) burns, which do not blanch on pressure. Full thickness (third degree) burns may be white, brown, or black and look \200\230leather y \200\231. They do not blister and have no sensation. On the day of injury it may be dif \201 cult to distinguish deep super \201 cial (second degree) burns from full thickness (third degree) burns, but correctly making this distincti on does not alter the initial management. 391 BURNS: ASSESSMENT A A 1 1 2 2 2 2 13 13 11 /2 11 /2 11 /2 11 /2 21 /2 21 /2 11 /2 11 /2 11/2 11 /2 1 B B B B C C C C 13/4 13/4 13/4 13/4 Fig. 8.16 Assessing extent of burns \200\224 Lund and Browder charts. Table 8.5 Relative percentage of area affected by growth (age in years) 0 1 5 10 15 Adult 9 1 / 2 8 1 / 2 6 1 / 2 5 1 / 2 4 1 / 2 3 1 / 2 A: half of head 2 3 / 4 3 1 / 4 4 1 / 2 4 1 / 2 4 3 / 4 4 B: half of thigh 2 1 / 2 2 1 / 2 2 3 / 4 3 1 / 4 3 1 / 2 3 C: half of leg Adults rule of 9 \200\231s: head = 9 % each arm = 9 % each leg = 18 % front of trunk = 18 % back of trunk = 18 % perineum = 1 % Infants rule of 5 \200\231s: head = 20 % each arm = 10 % each leg = 20 % front of trunk = 10 % back of trunk = 10 % 392 CHAPTER 8 Major trauma Major burns: resuscitation Prehospital \201 rst aid measures \200 Ensure rescuer safety \201 rst \200\224 be guided by the \201 re crew. \200 Remove the patient from the b urning environment. If clothes are smoul- dering, apply cold water and remove them, unless adherent. Provide high \202 ow O 2 . Cover burns in clean sheets. Airway and cervical spine protect ion \200 Treat airway obstruction ( b p.320). \200 Continue O 2 and apply a hard cervic al collar if there is any possibility of spinal injury \200\224 cervical spine imaging wil l be required subsequently. \200 If there is any evidence of impending airway obstruction (stridor, oropharyngeal swelling \200\224 see b p.394), call immediately for senior ED he lp and a senior anesthetist. Urgent GA and tracheal intubation may be life-saving. Use uncu t endotracheal (ET) tubes to allow for swelling of lips and face. Analgesia \200 Obtain IV access with two large peripheral cannulae. \200 Send blood: X- matching, FBC, COHb, U&E, glucose, and coagulation. \200 Provide analgesia (IV morphine t itrated according to response). \200 Provide an antiemetic (eg IV cyclizine 50mg). Fluid resuscitation \200 Give IV \202 uids. Start with isotonic crystalloid (eg 0.9 % s aline) at 2 \200\2234mL of crystalloid per kg body weight per % body surface area burned, o ver the \201 rst 24hr following injury. Give half of this volume in the \201 rst 8hr. Check pulse, BP, and respiratory rate every 10 \200\22315min initially. \200 Insert a uri nary catheter and test the urine. Patients with myoglobinuria are at particularly high risk of acute renal failure \200\224 reduce this risk by adequate \202 uid resuscitation. Us e urine output to guide \202 uid therapy. \200 Review the rate of IV volume replacement frequently and adjust it according to haemodynamic parameters, in order to maintain a sati sfac- tory urine output ( > 50mL/hr in adults; 1 \210\222 2mL/kg/hr in children). Some burns units prefer a colloid (eg Gelofusine or albumin) to form a component of the initial volume replacement: follow local policy. Patients with full thickness burns of body surface area > 10 % may require red cell transfusion in addition to the above measures. Breathing \200 Check COHb and ABG. \200 Circumferential full thickness chest burns rest ricting chest movement require escharotomy. Cut the burnt areas down to viable tissue to re lease the constriction. Cutting diathermy can be helpful to reduce the signi \201 cant blo od loss involved in extensive escharotomy. Obtain a CXR. 393 MAJOR BURNS: RESUSCITATION The burn \200 Measure the area of the burn as a % of body surface area. \200 Irrigate c hemical burns with warmed water (see b p.396). \200 Cover the burn with cling \201 lm o r dry sterile sheets. Do not apply extensive burns dressings before assessment by a burns specialist. Involve a burn specialist at an early stage \200\224 in the UK, the National Burn Bed Bureau will help to locate a suitable bed (tel. 01384 215576). Ensure tetanus prophylaxis, but avoid \200\230routine \200\231 prophylactic antibiotics. The burnt patient in cardiac arrest \200 Follow standard guidelines. \200 Give a large bolus of IV \202 uid. \200 If there is a strong possibility of cyanide poisoning (eg bu rnt plastic furniture in a house \201 re), give appropriate antidote, eg dicobalt edetate (see b p.207). Vascular impairment to limbs and digits Consider the need for longitudinal escharotomies. T hese are occasionally needed if ischaemia causes severe pain: get advice from a burns speci alist. 394 CHAPTER 8 Major trauma Inhalation injury The commonest inhalation injury is smoke inhalation accompanying burns in house \201 res. Inhalation injury alone may be fatal and it i mortality for a given body surface area of burn. Smoke is a complex and unpredictably variable mixture of solid, liqu id and gas constituents. Common components of inhalation injury include: \200 Direct thermal injury. \200 Soot p articles cause local injury to the cilia of the respiratory tract and obstruct small airways. \211\210 85 % of \201 re deaths are caused by CO ( b p.208). \200 Gas products of comb ustion : oxides of sulfur, nitrogen, ammonia, chlorine, hydrogen cyanide, phosgene, isocyan ates, ketones, and aldehydes are highly irritative and cause laryngospasm. Some react with water in the respiratory tract producing strong acids which cause bronchospasm, mucosal inj ury and oedema. The nature of the inhaled insult determines the site, severity, and systemic features. The upper respiratory tract can dissipate heat ef \201 ciently, so that direct thermal injury to the lower respiratory tract is rare unless steam or other hot vapors are inhaled. In the lower airway, toxic components such as CO, oxides of sulfur, nitrogen, hydrogen cyanide, h ydrogen chloride cause direct injury, and may act as systemic poisons. Clinical features Suspect smoke inhalation if any of the following features are present: ex posure to smoke or \201 re in an enclosed space, confusion or altered/loss of consciousne ss, oropharyngeal burns, hoarseness/loss of voice, singed nasal hairs, soot in nostrils or sputum, wheeze, dysphagia, drooling or dribbling, stridor. Investigations Peak \202 ow rate Determine this in all patients. ABG Detection of hypoxia, hypercapnia, and acidosis may be helpful, but does not correlate well with the severity of inhalation injury. Note that pulse oximetry has limited value bec ause of the dif \201 culty in distinguishing between oxyhaemoglobin and COHb. CXR Usually normal initially, later features of ARDS may develop. Carboxyhaemoglobin (COHb) CO poisoning cannot be detected by physical examination, SpO 2, o r pO 2 . Either arterial or venous COHB can be measured. Clinical features correlate poorly with COHb levels. Use the nomogram opposite to estimate COHb levels at the time of exposur e. The management of CO poisoning is covered on b p.208. ECG CO binds to myoglobin 3 \227 more avidly than to Hb and by affecting the myocardium may produce arrhythmias, ischaemia, or even MI. Fiber optic bronchoscopy, xenon lung scanning, ventilation-perfusion scans, or lung functio n testing may subsequently be required to assess lung problems due to inhalational injury. 395 INHALATION INJURY Management Signs of upper airway problems (facial burns, stridor, dysphagia, drooling, d co nsciousness) indicate the need for early tracheal intubation by an experienced doctor (ED/I CU/anesthesia) with appropriate training. Mucosal swelling in the oropharynx and epiglottis can progress rapidly and necessitate a surgical airway ( b p.326). A surgical airway in th ese circum- stances can be dif \201 cult due to burned skin and loss of landmarks. Meticul ous preparation and planning for the airway are essential. Flexible bronchoscopy may help t o assess thermal injury to the upper airway and help intubation. Assisted ventilation with PEEP may be indicated. Give the highest possible concentration of humidi \201 ed O 2 . Hyp erbaric O 2 may be indicated for CO poisoning, but remains controversial ( b p.208). If bro nchospasm occurs, give nebulized B 2 agonist (salbutamol 5mg) via an O 2 powered nebulizer. i in microvascular permeability leads to pulmonary oedema 2 \200\2233 days after injury an d pneumonia after 7 \200\22314 days. Pulmonary \201 brosis is common among survivors. Ina dequate IV \202 uid resuscitation is associated with greater pulmonary oedema. Burned pat ients who have smoke inhalation need larger amounts of IV \202 uids to maintain cardiac a nd urine output. Inhalation of HCN from smoldering plastics (eg polyurethane) results in ra pid systemic absorption. Measurement of blood CN concentration is dif \201 cult and takes several hours. Cyanide poisoning may be suggested by a severe metabolic acidosis, a high la ctate and i anion gap. Consider cyanide antidotes ( b p.207), but they are potentially toxi c so do not use blindly. There is no proven bene \201 t from steroid therapy. Nomogram of decay of COHb with time This nomogram (Fig. 8.17 ) allows back-calculation esti mation of the likely peak COHb level. It will considerably under-read for children and pati ents who received a high prehospital FiO 2 . 100% 90 80 70 60 50 100% 80 60 50 40 30 40 30 TIME SINCE EXPOSURE 20 20 1 2 10 8 6 3 10 Original exposure concentration 4 4 Hours Measured 5 concentration Fig. 8.17 Adapted from Clark et al . (1981). 396 CHAPTER 8 Major trauma Management of smaller burns Assessment ( b p.390) First aid measures Separate the patient and burning agent. Cool affected area with copious quantities of cold water, but beware of hypothermia in infants and young children. Need for admission Admit patients with large burns or signi \201 cant smoke inhalation for IV \202 uids, resuscitation and analgesia. In the UK, the National Burn Bed Bureau will search for an appropriate bed (Tel: 01384 215576) after discussion with the local burns uni t. Also refer for admission burns of suspected NAI origin and patients who would be unable to cope at home (eg an elderly person or if living in dif \201 cult social circumstances). Referral to a burns specialist Refer patients with the following: \200 Airway burns. \200 Signi \201 cant full thickness burns, especially over joints. \200 Burns > 10 % . \200 Signi \201 cant burns of special areas (hands, face, perineum, feet). The burn wound \200 Leave full thickness burns uncovered and refer to a specialist. \200 Do not de-roof partial thickness burns with blistering \200\224 consider simple aspirati on. Most can be cleaned and covered with an appropriate dressing (see below). Hand burns Consider covering with soft paraf \201 n inside a polythene bag or glove sealed at the wrist, changed after 24hr. Simple paraf \201 n/tulle dressings are an alternative \200\224 follow local policy. Elevate to minimize swelling. Avoid silver sulphadiazine cre am except on specialist advice. Facial burns Leave uncovered, or consider application of soft paraf \201 n. Eye burns Check VA and refer to a specialist with prior irrigation if chemical burns ( b p. 538). Perineal and foot burns Burns in these areas should be referred for burns unit admiss ion as they require specialist nursing and wound care. Burns dressings The ideal burns dressing is sterile, non-adherent, and encourages wound hea ling in a moist environment. The diversity of dressings available re \202 ects the fact th at this ideal dressing remains elusive. Senior ED nursing staff will advise on local prefer ence and policy. Accumulation of \202 uid means that many dressings need to be changed at \211\210 48hr \200\224 often this is appropriately done at a GP surgery. 397 MANAGEMENT OF SMALLER BURNS Analgesia and tetanus Unless there is a contraindication and/or if the patient is elderly, NSAID is appropriate and effective analgesia for many burns, which do not require admission . Ensure prophylaxis against tetanus. Burns in children and non-accidental injury Unintentional burns are common in children \200\224 use the opportunity to offer advice regarding injury prevention. A minority of bur ns may result from NAI. Suspect NAI ( b p.730) and seek senior help in the following situat ions: \200 When the explanation does not \201 t the burn. \200 Late presentation. \200 Other suspicious injuries. \200 Stocking and glove distribution scalds ( sparing of the buttocks) \200\224 this implies forced immersion in hot water. Circular full thickness burns \211\210 0.75cm diameter may represent cigarette burns. Chemical burns Initial assessment is notoriously dif \201 cult. Alkalis tend to produce mo re severe burns and can continue to penetrate even after initial irrigation. Treat chemical burns with copious irrigation with water, continued for at least 20min in al kali burns. Hydro \202 uoric acid burns Hydro \202 uoric acid is used industrially in a number of pro cesses. Contact with the skin causes particularly severe burns, often with signi \201 cant tissue damage and severe pain. This is because hydro \202 uoric acid rapidly crosses lipi d membranes and penetrates the tissues deeply, where it releases the highly toxic \202 uo ride ion. Fluoride ions may gain access to the circulation and produce a variety of systemi c problems by a variety of mechanisms, including interfering with enzyme systems and produc ing hypocalcaemia by binding to calcium. Manage hydro \202 uoric acid burns as follows: \200 Provide copious lavage to the affect ed skin then apply iced water (this provides better pain relief than calcium gluconate gel). Call a plastic surgeon at an early stage. \200 Check serum Ca 2 + and Mg 2 + , and U&E. \200 Record an ECG and place on a cardiac monitor. \200 Treat hypocalcaemia. Cement burn s Wet cement or concrete can cause chemical burns due to the alkali contact. These are usua lly partial thickness, but may be full thickness. They often occur when wet cement falls in to a work boot, but the burn is not initially noticed. Involve a specialist at an early sta ge. Phenol burns Phenol may be absorbed through the skin, resulting in systemic toxicity and re nal failure. Get advice from Poisons Information Service ( b p.181). 398 CHAPTER 8 Major trauma Crush syndrome A spectrum of conditions characterized by skeletal muscle injury (rhabdomyol ysis). Causes include : \200 Direct injuries and severe burns causing muscle damage. \200 Compartment syndromes: \200\230true \200\231 crush injuries produced by entrapment, or \200\230self-crushing \200\231 (eg an unconscious individual from drug overdose or alco hol excess lying on a hard surface). A vicious cycle is established where i muscle compartm ent pressure obstructs blood \202 ow, the muscles become ischaemic and oedematous, furthe r i compartment pressure and d blood \202 ow leading to more ischaemia and muscle cell de ath. Non-traumatic causes: metabolic disorders (diabetic states, d K + , d PO 4 3 \200\223 ), my xoedema, neuroleptic malignant syndrome, myositis due to infection, or immunological diseas e. Exertional: from undue exertion, grand mal \201 tting, rave dancing (particularly associa ted with ecstasy or cocaine use), often complicated by hyperthermia. Clinical features Adopt a high index of suspicion. Symptoms depend on the underlying cause, but muscle pain, tenderness and swelling may not be present at the time of admission. In t he lower limbs, the condition is commonly confused with DVT. The classic compartment syndro me with pain on passive muscle stretching and sensory de \201 cits may take several days t o develop and can pass unnoticed. The presence of distal pulses does not rule out a compart ment syndrome. Investigations i CPK levels re \202 ect muscle damage. Check U&E, PO 4 3 \200\223 , Ca 2 + and urate. 70 % have myoglobinuria and pigmented granular casts (urinary stix tests do not differentiate between Hb and myoglobin). However, absence of myoglobinuria does not exclud e rhabdomyolysis, as myoglobin clears rapidly from plasma and its presence in urine depends upon the release rate, the degree of protein binding, GFR, and urine \202 ow. If DIC is suspected, check a coagulation screen. 399 CRUSH SYNDROME Treatment Local problems Urgent orthopedic referral is needed for compartment syndromes. If the difference between intra-compartmental and diastolic pressures is <30mmHg, fasciotomy, excision of dead muscle and even distal amputation may be required. These procedures may i nduce life-threatening electrolyte shifts, bleeding, local infection, and later generalized sepsis. Systemic complications Severe metabolic complications start after revascularization. Hyperk alaemia may be life-threatening ( b p.162). Hypocalcaemia is common initially, but rarely s ymptomatic. Acute renal failure can be produced by pre-renal, renal, and obstructive elements. Followin g restoration of circulation or release from entrapment, \202 uid leaks into damaged area s d circulating plasma volume. Intracellular muscle contents enter the circulation and myog lobin and urate crystals can block the renal tubules. This process is aggravated by the d i ntravascular volume and associated metabolic acidosis. DIC and drugs which inhibit intra-re nal homeostatic mechanisms (eg NSAIDs and B -blockers) may also contribute. Prompt correction of \202 uid de \201 cits and acidosis (often with CVP monitoring) and establishing a good urinary \202 ow is essential. Alkalinization of the urine may be requ ired: early use of mannitol has been advocated, but can cause pulmonary oedema if renal imp airment is already present. If renal failure occurs, dialysis may be needed, but prospects for renal recovery are good. This page intentionally left blank 401 Chapter 9 Wounds, fractures, orthopedics Elbow injuries Soft tissue elbow problems 450 The approach to wounds 402 Further assessment of skin 452 wounds 404 406 410 411 412 Anterior shoulder dislocation Wound management Tetanus prophylaxis Antibiotic prophylaxis Wound aftercare Infected wounds and 454 Other types of shoulder dislocation 456 458 Other shoulder injuries Soft tissue shoulder cellulitis Bite wounds Speci \201 c bites and stings Needlestick injury Puncture wounds Ho w to describe a 413 414 416 418 419 problems 460 462 464 466 Soft tissue neck injuries Facial wounds Pelvic fractures Hip dislocations and acetabular fractures 468 420 422 Compound fractures Dislocations 423 Casts and their problems 424 Soft tissue injuri es 426 Other soft tissue problems fracture Sacral and coccygeal 469 fractures 470 Hip fractures Shaft of femur fractures 472 Approach to knee injuries 474 Knee fractures and dislocations 427 Physiotherapy in the ED 428 Approach to hand injuries 430 Clinical signs of hand 476 478 479 Soft tissue knee injuries Other knee problems Tibial and \201 bular shaft injury 432 fractures 480 481 Hand wounds and Pretibial lacerations Calf and Achilles tendon associated injuries 434 Hand fractures and dislocations injuries 482 436 Approach to ankle Thumb fractures and 438 440 injuries 484 dislocations Soft tissue hand injuries Other soft tissue hand Ankle fractures and dislocations Ankle sprains Foot fractures and dislocations 486 487 problems 441 Carpal bone fractures and dislocations Colles \200\231 fracture Other wrist fractures Soft tissue wrist injuries/ 442 444 446 488 490 491 492 494 498 Toe injuries Soft tissue foot problems Low back pain Acute arthritis Eponymous fractures 447 Forearm fractures and related 448 problems injury 402 CHAPTER 9 Wounds, fractures, orthopedics The approach to wounds Wounds often have medicolegal implications \200\224 therefore recor d notes thoroughly, legibly, and accurately ( b Note keeping, p.4). Resuscitation is the in itial priority for the seriously wounded patient. Stop bleeding by applying direct pressure . History Key questions are: \200 What caused the wound? (knives/glass may injure deep stru ctures). \200 Was there a crush component? (considerable swelling may ensue). \200 Wher e did it occur? (contaminated or clean environment). \200 Was broken glass (or china) inv olved? (if so, obtain an X-ray). \200 When did it occur? (old wounds may need delayed clo sure + antibiotics). \200 Who caused it? (has the patient a safe home to go to?). \200 Is tetanus cover required? (see b p.410). Examination Consider and record the following: \200 Length : preferably measure. If not, use the term \200\230approximately \200\231 in the notes. Site : use diagrams whenever possible (rubber stamps are recom- mended). Consider taking di gital photographs, particularly for com- pound fractures, in order to minimize the risk of infection by disturbing the wound as little as possible prior to surgery. Orientation : vertical, horizontal or oblique. \200 Contamination : by dirt or other FBs may be obvious. \200 Infection : either localized or spreading, is a feature of delayed p resen- tations and is associated in particular with certain speci \201 c injuries (eg \200\230reverse \201 ght bites \200\231 \200\224 see Bite wounds). Neurological injury : test and record motor and sensory components of relevant nerves. Be a ware that complete nerve transection does not automatically result in complete loss of sens ation \200\224 some feeling is likely to be preserved (particularly in the hand). Assume t hat any altered sen- sation re \202 ects nerve injury. Tendons : complete division is usually apparent on testing. Partial tendon division is easi ly missed unless the wound is carefully examined \200\224 the tendon may still be capable of performing its usual function. Look in the wound whilst moving the relevant joint, and a ttempt to re-create the position of the injured part at the time of injury (eg clenched \201 st) to bring the injured structures into view. \200 Vascular injury : check for dist al pulses. \200 Depth : wounds not fully penetrating the skin are \200\230super \201 ci al \200\231. Do not try to judge depth of other wounds before exploration. In some circumst ances (eg neck wounds), exploration is not appropriate in the ED. Type of wound : inspection often allows wounds to be described, helping to determine the me chanism of trauma (blunt or sharp injury) and hence the risk of associated injuries. The cr ucial distinction is whether a wound was caused by a sharp or blunt instrument. If in doubt , avoid any descriptive term and simply call it a \200\230wound \200\231. This avoids inac curacy and courtroom embarrassment! Use the terms as described opposite. 403 THE APPROACH TO WOUNDS Forensic classi \201 cation of wounds and injury The expert forensic evaluation of injury is outside the remit of the ED specialist, but a simple understanding helps to avoid incorr ect use of terminology with associated confusion (and sometimes embarrassment). Incised wounds May also be referred to as \200\230cuts \200\231. Caused by sharp injury (e g knives or broken glass) and characterized by clean-cut edges. These typically include \200\230stab \200\231 wounds (which are deeper than they are wide) and \200\230slash \200 \231 wounds (which are longer than they are deep). Lacerations Caused by blunt injury (eg impact of scalp against sidewalk or intact glass bot tle), the skin is torn, resulting in irregular wound edges. Unlike most incised wounds, tis sues adjacent to laceration wound edges are also injured by crushing and will exhibit evide nce of bruising. Puncture wounds Most result from injury with sharp objects, although a blunt object with su f \201 cient force will also penetrate the skin. Abrasions Commonly known as \200\230grazes \200\231, these result from blunt injury applie d tangentially. Abrasions are often ingrained with dirt, with the risk of infection and in the longer term, unwanted, and unsightly skin \200\230tattooing \200\231. Skin tags visibl e at one end of the abrasion indicate the edge of skin last in contact with the abrading su rface and imply the direction in which the skin was abraded. Burns See b p.390. Bruises Bru ising re \202 ects blunt force (crush) injury to the blood vessels within the tissues, res ulting in tender swelling with discoloration: sometimes localized bleeding collects to form a haematoma. The term \200\230contusion \200\231 is sometimes used as an alternative for bruise \200\224 it has no particular special meaning (or value). Record the site, size, co lor, and characteristic features of any bruising. It is impossible to determine the exact a ge of a bruise from its color. However, yellow color within a bruise implies (except in the neonate) that it is > 18hr old. Scratches These may comprise either a \200\230very super \201 cial incision \200\231 or a \200\230long, thin abrasion \200\231 \200\224 leave the distinction to an expert. Interpersonal violence \200\224 medicolegal implications Victims of violence frequently at tend ED for treatment of their injuries. Some patients (particularly those who have suffere d domestic violence) may not provide an accurate account of how the injuries occurred and m ay not seek involvement of the police. Classical defense wounds include: \200 Isolated ul na shaft fracture as the arm is raised to protect against blunt injury. Incised wounds on the palmar aspects of the palms and \201 ngers sustained in attempts to protect against knife attack. In cases where the police are involved and where injuries are serious or extensive, the pol ice may arrange to obtain photographs and a forensic physician (police surgeon) may be invo lved in the role of documenting injuries. Most ED patients who have suffered violence do no t see a forensic physician (police surgeon). Therefore, ED staff have a dual role of treati ng injuries and recording them accurately for medicolegal purposes. 404 CHAPTER 9 Wounds, fractures, orthopedics Further assessment of skin wounds Investigation X-ray if there is suspicion of fracture, in volvement of joint, penetration of body cavity or FB. Specify on request forms that a FB is being sought, to allow appropriate views and exposure. Most metal (except aluminum) and gl ass objects > 1mm in diameter will show up on X-ray. Some objects (eg wood) may not: USS ma y demonstrate these. CT or MRI are also occasionally helpful. Note: X-ray all wounds from glass that fully penetrate the skin During X-ray, use radio-opa que markers (eg paper clip) taped to the skin to identify the area of concern. Wound swabs for bacteriology are unhelpful in fresh wounds, but obtain them from older wounds showing s igns of infection. By far the most important investigation is: Wound exploration under appr opriate anesthesia Allows full assessment and thorough cleaning of wounds that extend fully through the skin. Do not explore the following wounds in the ED: \200 Stab wounds to the neck, chest, abdomen, or perineum. \200 Compound fracture wounds requiring surgery in th eater. \200 Wounds over suspected septic joints or infected tendon sheaths. \200 Most w ounds with obvious neurovascular/tendon injury needing repair. \200 Other wounds requirin g special expertise (eg eyelids). Obtain relevant X-rays beforehand. Adequate anesthesia is essential \200\224 in adults LA (eg 1 % plain lidocaine) is often suitable ( b p.282), bu t document any sensory loss \201 rst (if there is altered sensation, presume nerve injury and refer for formal exploration in theater). Do not inject LA into the edges of an infect ed wound: it will not work in that acidic environment and it may spread the infection. GA m ay be the preferred option for treating some wounds in young children. Inspect wounds for F Bs and damage to underlying structures. Most problems with wound exploration relate to blee ding. If it proves dif \201 cult to obtain a good view: \200 Obtain a good light and an assistant. The assistant retracting on a stitch placed on either side of the middle of the wound allows full exposure. \200 Press on any bleeding point for \211 1min, then look a gain. Lidocaine with adrenaline ( b p.283) is useful in scalp wounds which are bleeding pro fusely. If bleeding continues, consider a tourniquet for up to 15min. Consider a sphygmomanometer B P cuff in \202 ated above systolic pressure (after limb elevation for 1min) on the limbs, or a \200\230 \201 nger \200\231 of a sterile rubber glove may be used on \201 ngers or toes. Never leave a patient alone with a tourniquet on, lest it is forgotten. Ensure remov al of the tourniquet afterwards. Record the time of application and removal. If these measures fail, refer for specialist exploration in theater. Do not blindly \200 \230clip \200\231 bleeding points with artery forceps, for fear of causing iatrogenic neuro vascular injury. Sometimes, small blood vessels in the subcutaneous tissues can be safely l igated using an appropriate absorbable suture (eg 4/0 or 6/0 Vicryl (braided polyglactin) o r Dexon). 405 FURTHER ASSESSMENT OF SKIN WOUNDS The approach to foreign bodies FBs within soft tissues can cause pain, act as a focus for i nfection, or migrate and cause problems elsewhere. Therefore, remove FBs from recent wounds where possible, particularly if lying near a joint (but if FB is within a joint, refer to the orthopedic team for formal exploration and removal). FBs which can be seen or felt or a re causing infection are usually best removed. Finding FBs is frequently dif \201 cult wit hout a bloodless \201 eld and good light. It may be appropriate to leave some FBs, such a s gunshot deeply embedded in buttock soft tissues (antibiotic cover advised). However, most FBs of any size not removed in the ED warrant specialist consideration. Patients not infrequently present with symptoms relating to (suspected) FBs under old heale d wounds. In these circumstances, refer to an expert for exploration under appropriate cond itions. Fishhooks The barbs on some \201 shhooks can make removal dif \201 cult. In some cases, it may be necessary to push a \201 shhook onwards (under LA) and thus out through the ski n \200\224 wire cutters can then cut through the hook below the barb and allow release. We ar eye protection when doing this. There are alternative methods for removing \201 shhooks. Smaller \201 shhooks that are relatively super \201 cially embedded can sometimes be pulled back and removed through the entry wound once a hollow needle has been advanced alongside the hook to cover the barb. 406 CHAPTER 9 Wounds, fractures, orthopedics Wound management Wound cleaning Thoroughly clean all wounds irrespective of whether closure is contemplated, to d risk of infection. The standard agent used for wound cleaning is 0.9 % (normal) saline, possibly preceded by washing using tap water. Aqueous chlorhexidine or 1 % cetrimide solutions are sometimes used. Do not use hydrogen peroxide or strong povidone iodine solutions. Wounds ingrained with dirt may respond to pressure saline irrigation (19 G needle attached to 20mL syringe), or may require to be scrubbed with a toothbrush (use go ggles to d chance of conjunctival \200\230splashback \200\231). Devitalized or grossly con taminated wound edges usually need to be trimmed back (debrided), except on the hand or fac e. If dirt or other foreign material is visible despite these measures, refer to a speciali st, who may choose to leave the wound open. Wound closure There are three recognized types of wound closure: Primary closure Surgical closure (by whatever physical means) soon after injury. Secondary closure No intervention: heals by granulation (secondary intention). Delayed primary closure Surgical closure 3 \200\2235 days after injury. If there is no underlying injury or FB, treat fresh wounds by primary closure as soon as po ssible. Accurate opposition of wound edges and obliteration of dead space provides the best cosmetic outcome with least infection risk. Wounds not usually suitable for primary closure in the ED include: \200 Stab wounds to th e trunk and neck. \200 Wounds with associated tendon, joint or neurovascular involvement. \200 Wounds with associated crush injury or signi \201 cant devitalized tissue/ skin loss. Other heavily contaminated or infected wounds. \200 Most wounds > 12hr old (except clean facial wounds). Methods of closure If in doubt, sutures are usually the best option (see opposite).