IMPORTANT NOTE: JAAPA CME activities consist of 2 articles. To obtain credit, you must also read
Abdominal compartment syndrome: Potentially lethal and easy to miss; the post-test will include questions related to both articles. AAPA Fellow members should complete and submit the post-test on the AAPA Web site by going to
www.aapa.org and searching for keyword
JAAPA post-tests. All others may complete and submit the post-test online at no charge at
www.mycme.com. To obtain 1 hour of AAPA Category I CME credit, PAs must receive a score of 70% or better on each test taken.
KEY POINTS
■ The goals of managing open wounds are to avoid infection, minimize bleeding, close dead space, achieve an aesthetically pleasing scar, and minimize discomfort for the patient.
■ Determining mechanism of injury, taking a patient history, and examining the wound are essential first steps.
■ Topical anesthesia may be used before local anesthesia or digital block for better pain control before cleansing, debridement, and wound closure.
■ Choice of suture material and technique should be matched to the location and nature of the injury; alternative wound closure techniques may be used in appropriately selected patients.
Patients with lacerations are frequent visitors to the emergency department (ED) and account for approximately 11 million visits yearly.1,2 Blunt force trauma, sharp instruments, glass, wooden objects, and bites are common causes of lacerations.1,2 The clinician must understand the mechanism of injury to understand its magnitude.1,2 Practitioners should be familiar with different methods of wound closure, including suturing, tissue adhesive, staples, and skin closure tapes. The primary objectives of basic wound management are to promote optimal healing and cosmesis.1
FIRST STEPS IN WOUND MANAGEMENT
The goals of managing open wounds are to avoid infection, minimize bleeding, close dead space, achieve an aesthetically pleasing scar, and minimize discomfort for the patient.2,3 Wound closure creates the tensile strength that holds the wound edges together and provides an effective seal until healing takes over.2-4 To achieve these goals, the proper materials and technique must be chosen.
Mechanism of injury When evaluating a wound in the ED, providers must consider the risk of embedded foreign objects, infection, and tendon laceration. A comprehensive history that includes time and mechanism of injury is therefore important because it suggests whether a foreign body or fracture might be present. The wound should be properly explored (after bleeding is controlled) for foreign bodies or tendon injury. Radiographs should be ordered if a fracture or foreign body is suspected. Even if imaging does not reveal a foreign body, the wound should be gently probed and explored. Radiographs miss a large portion of glass foreign bodies that are smaller than 0.5 mm.5 If the wound is contaminated with dirt and debris, extra attention must be paid to the irrigation process to reduce the risk of infection.
History Wound management requires attention to such details as the patient's tetanus status, history of diseases that might adversely affect healing, and allergies.6 A tetanus booster should be administered if vaccination status is not up-to-date. In addition, complicating factors such as extremes of age, diabetes mellitus, and use of immunosuppressive agents like chemotherapy or corticosteroids should be considered.1,3,7 A 48-hour wound check is necessary under these circumstances.
Physical examination When examining a wound, the PA should use good lighting and equipment in a sterile environment with minimal bleeding.7,8 Motor function, sensation, and pulses distal to the wound should always be assessed and documented.1,2 A surgical consult should be considered for deep wounds of the hands or feet; open fractures; tendon involvement; extreme contamination; bone, joint, artery, or nerve involvement; crush injuries; deep penetrating wounds; eyelid, lip, or ear lacerations; and wounds where scarring is of large concern.1,6
ANESTHESIA
Local anesthesia can be achieved by infiltration with a needle into the wound. Lidocaine (Lidopen, Xylocaine, generics), lidocaine with epinephrine (Lignospan, Octocaine, Xylocaine with epinephrine, generics) and bupivacaine (Marcaine, Sensorcaine, generics) are the most common agents used and vary somewhat in onset and duration (Table 1). The use of epinephrine will help to obtain hemostasis and increase the duration of anesthesia. Epinephrine causes vasoconstriction of the end arterioles, so it should be avoided at distal sites such as the digits, nose, penis, and ears as well as in areas with devitalized tissue and flaps because of the risk of necrosis.2,5 Bupivacaine provides longer relief but does not work well on the digits and should not be used on the lips.5
A 25- to 27-gauge needle should be used and the anesthetic injected in a fanlike pattern around the wound and the surrounding area.9,10 When injecting, pull back with slight traction on the plunger to ensure you avoid blood vessels. In addition to using a small-gauge needle, other ways to minimize the pain associated with administration of local anesthetics are warming the solution to body temperature, buffering with sodium bicarbonate to decrease acidity (1:10 solution), injecting slowly, using a topical anesthetic prior to injection, and injecting through wound edges where there are fewer nerve endings instead of through intact surrounding skin.3,5,9
Topical anesthetics numb the skin and are noninvasive and effective.9,11 LET (lidocaine, epinephrine, tetracaine) has shown to be somewhat superior to EMLA (eutectic mixture of lidocaine and prilocaine).12 These preparations can be applied generously to the wound and covered with an occlusive dressing for 15 to 20 minutes, by which time anesthesia typically occurs. Leaving the dressing in place up to 60 minutes will achieve better results. Topical anesthetics work best in highly vascularized areas such as the face. Skin blanching (secondary to the epinephrine in the topical anesthetic) is a reliable indication that the area is anesthesized.5 Remember that topical anesthetics (like local anesthetics) that contain epinephrine such as LET should not be used distally or near mucous membranes.9
Digital blocks are used to provide more complete anesthesia in fingers. Local infiltration of a digit can require large doses in a small area and interfere with approximation of wound edges. The nerve block prevents distorted tissue in an area where precision and alignment are important.9,13
The volar technique, which has been found to be significantly less painful than a dorsal block,14 calls for 2 mL of anesthetic to be injected just short of the flexion crease of the volar aspect of the digit with a single needlestick15 (Figure 1). In the dorsal technique, a needle is inserted at the dorsal aspect of the extensor hood and then advanced to the volar aspect (Figure 2); 1 mL is injected in each area at the web space and then repeated on the other side of the finger. No more than 5 mL should be used in each finger.14