Events Surrounding the Injury

Timing of the Injury
It is best to close an open wound within 6 hours of injury. Do not close
a wound after 6 hours because the risk of infection becomes unacceptably
high.
Wounds on the face are exceptions to this rule. The face has an excellent
blood supply, which makes infection less likely. In addition, cosmetic
concerns are important. It is therefore acceptable to close a
wound on the face that is older than 6 hours (perhaps up to 24 hours or
at most 48 hours), as long as you can clean it thoroughly.
Nature of the Injury
• A wound caused by a clean knife has a low risk of infection.
• Adirty wound carries a risk for tentanus. Wood may break off and
leave pieces behind, increasing the risk for subsequent infection if
the wound is not explored and washed out thoroughly.

• Any wound that may contain a foreign body should be explored and
the foreign body removed.
• Animal bites, especially cat bites, often penetrate more deeply than
you think. Bites on the hand should raise concern about involvement
of an underlying joint. Oral bacteria may cause severe infections (see
chapter 36, “Hand Infections”). Always consider the risk of rabies.
• Human bites also are associated with specific oral bacteria that may
cause serious infections (see chapter 36, “Hand Infections”).
• If any object penetrated the patient’s clothing or shoes before piercing
the skin, the chance for infection is increased because pieces of
clothing may become embedded in the underlying tissues. If an
object penetrated the patient’s tennis shoes, be concerned about a
possible pseudomonal infection.
• Crush injuries may be associated with greater underlying damage
than initially appreciated (see chapter 35, “Crush Injury”).
• Gunshot wounds: see chapter 37, “Gunshot Wounds.”
• Thermal or electrical injury: see chapter 20, “Burns.”
Concerns about Tetanus
Table 2. Risks for Tetanus


Concerns about Rabies
Be aware of the risk of rabies in the area where you work. Some countries—
England, for example—have no cases of rabies because of tight
animal controls. In most other countries, rabies is a real concern.
The primary animals associated with rabies infections include bats,
raccoons, skunks, and foxes. Because different areas have a different
risk for specific animals, know your area. Dogs and cats also can be infected;
be sure to ask if the animal has been vaccinated against rabies.
Livestock, rodents (e.g., rats, mice, squirrels), and rabbits are almost
never associated with a risk of rabies.

If you have fears that the animal is rabid:
1. Thoroughly clean the wound with soap and water.
2. Administer human rabies immunoglobulin, 20 IU/kg total. If possible,
administer one-half of this around the wound, and give the rest
in the gluteal area intramuscularly (IM).
3. Administer one of the three types of rabies vaccines currently available:
1.0 ml IM in the deltoid area of adults and older children, outer
thigh (not gluteal area) in younger children. Repeat on days 3, 7, 14,
and 28.

About the Patient

Tetanus Immunization Status
Tetanus is a devastating disease, causing muscle spasms that can lead
to muscle rigidity and seizures. Without adequate treatment, one in
three adults with tetanus will die. Although immunization has made
tetanus uncommon, it always lurks in the background.
If the patient has not had a tetanus booster within 5 years, and the
wound is tetanus-prone (see Table 2), a booster should be given. If the
wound is not tetanus-prone but the patient has not had a tetanus
booster within 10 years, a booster should be given. Patients who have
never been immunized need human tetanus immunoglobulin as well as
tetanus toxoid followed by completion of the full tetanus toxoid series.


Note: Tetanus toxoid and immunoglobulin must be kept refrigerated at
all times during transport from the factory. This requirement may be a
problem in remote areas.
Pulsatile Bleeding at Time of Injury
Even if the patient is not bleeding at the time of your examination, the
history of bright red, pulsatile bleeding at the time of injury implies an
arterial injury. Athorough vascular exam is required, and formal surgical
wound exploration is almost always indicated.
Medical Illnesses
Patients with diabetes are more prone to infections and wound-healing
problems. Encourage diabetic patients to keep glucose levels well controlled
to decrease the risk of complications. Malnourished patients
and patients with human immunodeficiency infection (HIV) or a history
of cancer also have wound-healing difficulties.
Smoking History
Tobacco smoking dramatically decreases circulation to the skin and
slows down the wound-healing process. Medical professionals have a
duty to tell all patients not to smoke. But the patient with an open
wound should be specifically warned that smoking interferes with and
perhaps prevents the healing process. Smoking also increases the risk
for wound complications and poor cosmetic outcome.

EVALUATION OF AN ACUTE WOUND

KEY FIGURE:
Irrigating a wound


This chapter explains the basics for evaluation and treatment of an
acute wound. Proper evaluation helps to determine the appropriate
next step—formal wound exploration or wound closure.
The first step is to control blood loss and evaluate the need for other
emergency procedures (see chapter 5, “Evaluation of the Acutely
Injured Patient”). The second step is to obtain a thorough history
about the patient and the events surrounding the injury.

Needle Thoracostomy

Needle thoracostomy is a life-saving procedure that is easy to do in patients
with tension pneumothorax. All health care providers should be
aware of this technique.
If conscious, the patient with tension pneumothorax is severely short
of breath and blood pressure is low. If unconscious, the patient may
simply be hypotensive and not breathing well.
If you listen over the chest for breath sounds, you may appreciate a
loss of breath sounds on the side of the pneumothorax, but this may be
difficult to appreciate in the emergency setting.

Another method is to feel the patient’s neck. The trachea shifts away
from the side with the tension pneumothorax.
If you cannot hear breath sounds in either side of the chest, the trachea
is in the midline, and the patient is in shock, treat both sides of the
chest. The patient may have bilateral tension pneumothoraces.
Equipment Needed
1. Large catheter for intravenous access (12 or 14 gauge). A large-bore
needle can be used if a catheter is not available, but the catheter is
safer. The needle can injure an underlying structure more easily.
2. Betadine, if available.
Procedure
1. Apply Betadine to the chest. Simply pour it on—this is an emergency!
2. Place the catheter, with the needle in place, into the affected side of
the chest at the second interspace in the midclavicular line (the
imaginary line drawn perpendicular to the clavicle at its midpoint).
3. Locate the second interspace.
• The second interspace is the space between ribs 2 and 3.
• It can be located by feeling for the spot on the breastbone (sternum)
where the manubrium and sternum meet (the point where
you can feel an elevation in the bone as you rub your fingers up
and down the breastbone).
• Move your fingers to the right or left chest (depending on where
the problem is). You should be at the second interspace when you
are at the midclavicular line.
4. The intercostal vessels run just below each rib. To prevent injury to
these vessels, the catheter should be inserted into the chest at the
second interspace just above the third rib.
5. If you inserted a catheter, remove the needle, but leave the catheter
in place. You will hear a big whoosh from the escaping air.
6. Leave the catheter in place until help arrives.
7. If you used a needle, you should hear the air escape as soon as you
enter the pleural space. Leave the needle in place until help arrives.
8. The patient requires a chest tube for definitive treatment of the
pneumothorax, but you may have just saved the patient’s life.


Emergency needle thoracostomy. At the midclavicular line, insert a large (14-
gauge) needle or vascular catheter into the chest at the second interspace just
above the third rib. You will hear a large rush of air when the needle enters the
chest.

Bibliography
1. Creech O, Pearce CW: Stab and gunshot wounds of the chest. Am J Surg 105: 469–483,
1963.
2. Melio FR: Priorities in the multiple trauma patient. Emerg Med Clin North Am
16:29–43, 1998.
3. Simon RR, Brenner BE: Emergency Procedures and Techniques, 3rd ed. Baltimore,
Williams & Wilkins, 1994, pp 71–75.
4. Walls RM: Cricothyroidotomy. Emerg Med Clin North Am 6:725–736, 1988.
5. Walls RM: Management of the difficult airway in the trauma patient. Emerg Med Clin
North Am 16:45–61, 1998.

Case Study

An 18-year-old man is brought into the hospital after being stabbed in
the right upper arm with an icepick. He complains of pain in the arm
but otherwise seems to be uninjured. You roll up his sleeve to examine
the arm and see entrance and exit sites. Since he has good pulses in
the extremities, you think that he is stable. While you are doing some
paperwork, he becomes very short of breath and hypotensive. What
happened?
If you had removed his shirt, you would have seen that the puncture
went through the arm and into the right chest. A pneumothorax developed.
Because he was young and healthy, he was able to tolerate it
until the pressure built up in the chest cavity. At that point he developed
a tension pneumothorax—a true emergency!
Only when the patient is stable from the perspective of the ABCs can you undertake
specific evaluation of more obvious injuries.