Assessment and Management

ASSESSMENT OF ACUTE SKIN INJURIES

Wound TypeCauseClassificationManagement
Skin TearUsually simple trauma involving friction or shearing forceCategory 1 = No tissue loss (heals by primary intention)

Category 2 = Partial tissue loss (heals by mixed primary and secondary intention)

Category 3 = Epidermal flap absent (heals by secondary intention)
Category 1
- Bring tissue ends together and hold with steristrips, glue or sutures, with non-adherent dressing to manage exudate (eg melolin)

Category 2
- Mx is to bring whatever tissue ends present together and hold with steristrips, glue or sutures, with non-adherent dressing to manage exudate (eg melolin)

Category 3
- No tissue to fix down
- Management is dressings based to facilitate healing (eg mepital) and non-adherent dressings to manage exudate (eg melolin)

 

Wound TypeCauseClassificationManagement
Incision / Laceration- Lacerations are caused by blunt trauma and are usually irregularly shaped wounds.

- Incisions or incisional wounds are caused by clean, sharp edged object such as a knife or piece of glass.
Describe wound:
- Size of wound (Length, width and depth; when describing depth, consider what tissue is exposed)

- Type of wound (vertical / horizontal / flap including the direction that the tip of flap pointing, linear / stellate)
As per general management.

SUBJECTIVE EXAMINATION

  • History
    • Time of injury
    • Mechanism of injury (e.g. Blunt force, sharp object, bite)
      • Helps to predict infection risk, underlying injuries, foreign bodies
  • Always ask about other injuries
  • Circumstances(e.g. At work, assault, self-inflicted)
  • Symptoms (e.g. Numbness, weakness)

OTHER FACTORS

  • Explore other factors which may impact or influence your treatment:
    • Allergies
    • Medications
    • Past History
      • Conditions which decrease healing or increase infection risk
  • When last ate
  • Tetanus status
  • Social History
    • Occupation, handedness
  • General
    • Vital signs – ?sig blood loss
    • Other injuries (may be more important)

OBJECTIVE EXAMINATION

INITIAL EXAMINATION

  • Wound
    • Control active bleeding
    • Anatomic site / possible underlying structures injured
    • Importance of cosmetic outcome
    • Preliminary assessment of depth/severity
      • ?ED or Surgical Mx needed
      • Foreign bodies
  • Distal to wound (prior to anaesthesia!)
    • Vascular supply – pulses, cap return, colour
    • Nerve function – sensory, motor
    • Tendon function
    • Remove rings
    • ?ED or Surgical Mx needed

DETAILED EXAMINATION

  • After local anaesthesia, investigate:
    • Underlying structures damaged
    • Examine tendons/muscles through their full range of motion for damage
    • Foreign bodies

INVESTIGATIONS

  • Other than a thorough physical exam, most require no other
  • If suspicious of fracture or foreign body and location not visible, need to investigate further:
    • Xray (can show underlying fracture or radio-opaque foreign body
    • Ultrasound (can be useful for wood, small pieces of glass)
    • CT eg with headstrike / LOC

REFERRAL TO PLASTICS

The following injuries should be referred to plastics / hand specialists for assessment and followup:

  • All tendon, muscular, vascular, bony, nerve or other structure injuries
  • Wounds needing GA:
    • Younger children/ infants
    • All wounds needing extensive debridement
    • Large or multiple wounds
    • Require too much LA, too much time for ED Mx
    • Large flaps
    • Face
      • Vermillion border of lip, ear cartilage, where cosmetic outcome crucial
    • Hand/fingers
      • Partial / full digit amputations, nail bed injuries

PAIN RELIEF

  • Rest, elevate
  • Analgesics
    • Oral
    • IV
    • Local Anaesthesia

 

WOUND CLEANSING

  • Best means of infection prevention is wound cleaning/debridement – not antibiotics
  • Done post Local Anaesthetic infiltration
  • For a clean wound – Chlorhexidine 1% cleansing
  • For a dirty wound – needs thorough irrigation
    • Use normal saline – 60ml per square cm
    • Use 18 gauge cannula sheath with 20ml syringe

 

 

FOREIGN BODIES

  • Do not close a wound with a foreign body
  • Most glass shows on plain Xray, not all (need ultrasound)

 

WOUND DEBRIDEMENT

  • Ensure all devitalised tissue is debrided – if extensive area refer to Plastics
  • Viable tissue bleeds
  • Use a scalpel blade
  • Re-irrigate after debridement

WOUND CLOSURE GENERAL PRINCIPLES

  • Fix displaced tissue using appropriate methods (sutures, glue, steristrips, staples, dressings)
    • Use the most appropriate method to close the wound while minimisng infection. Steristrips and glue have a smaller chance of infection compared to sutures or staples which are a foreign body.
  • Secondarily, dress wound to manage exudate and minimise trauma on removal
  • Consider use of tubigrip in lower limb injuries especially, to both hold dressings on, but also to provide compression.

 

 

OTHER CONSIDERATIONS

TETANUS

  • Tetanus is a condition characterized by a prolonged contraction of skeletal muscle fibres. The primary symptoms are caused by tetanospasmin, a neurotoxin produced by the bacterium Clostridium tetani. Infection generally occurs through wound contamination and often involves a cut or deep puncture wound. As the infection progresses, muscle spasms develop in the jaw (thus the name “lockjaw”) and elsewhere in the body. Infection can be prevented by proper immunization and by post-exposure prophylaxis.
    • Tetanus prone wounds include those that:
      • Are Deep
      • Are Contaminated esp with soil and faeces or foreign bodies
      • Are Crush injuries
      • Have Delayed closure

TETANUS REQUIREMENT

  • Uncertain vaccination history or <3 doses of tetanus toxoid
    • Clean minor wounds – Tetanus toxin only
    • All other wounds – Tetanus toxin + Tetanus Immunoglobulin (250 IU)
  • History of 3 or more doses of tetanus toxoid
    • <5 years  – nil
    • 5-10 years – Tetanus toxin, unless very clean/minor
    • >10 years – Tetanus toxin

PROPHYLACTIC ANTIBIOTICS

  • For wounds with a high risk of infection:
    • Delayed presentation > 8 hours
    • Puncture wounds unable to be debrided adequately
    • Wounds on hand/ feet/ face
    • Underlying structures involved – bones/ joints/ tendons
    • Immunocompromised patient ,especially diabetics
    • Presumptive therapy: give IV prior to suture so antibiotic is in blood
    • Use antibiotic guidelines
      • Classically IV Kefzol 1gm then Keflex at home, add Flagyl if bite
      • Diabetic feet – high risk: Keflex and Flagyl

IMMOBILISATION

  • Consider immobilisation if wound traverses a joint or is at high risk of infection
  • Splinting is with plaster slabs/ finger slabs
  • Minimising movement minimises infection
  • Use slings and crutches to reduce limb movement

ELEVATION

  • The affected limb should be elevated to assist with bleeding and / or swelling