A review of the principles of emergency wound management including detailed guide to suture material.

Medical Student Clinical Pearl – June 2020

Robert Hanlon

@roberthanlon12

Case Report

You are a third year clinical clerk asked to go see a patient and assess their injuries. A 28 year old female, who is sitting upright in bed and texting her friends, came into the Emergency department via ambulance with a laceration over her right forearm and wrist. EMT vital signs are as follows: BP 128/84, HR 106, RR 18, Temp 37.2, O2 Sats 99% on RA, GCS 15, and Blood glucose 6.4 mmol/L. She weighs 60 kg. The paramedics had wrapped her arm with gauze, which has a blood tinged color to it.

What is your approach?

Emergency Wound Management

A – Ask yourself: is the patient stable or unstable?

• Based on this patient’s vital signs and the fact that they seem calm and comfortable in bed, they are stable. The tachycardia noted in the vitals is likely due to pain/stress at the time collection and when taken again in the ED her heart rate is 78 and regular.
• A critical wound (hemorrhage or arterial bleeding) will likely need immediate attention and the patient may be presenting with vital signs that suggest more instability (low BP, high HR, high RR, High Temp, low O2 Sats).
• If the patient is stable and not exsanguinating, then a brief history and physical should be performed. ^1,2 Obtain a brief history:

Arterial bleeding

B – Obtain a brief history:

Mechanism and timing of injury: The patient was carrying towels down the stairs to her pool, tripped and fell down 5 steps, landing on her right side and breaking through a glass panel on her deck. This occurred 45 minutes ago.

Potential for concurrent injuries based on mechanism: The patient denies any loss of consciousness or head trauma. Denies any pain besides the laceration and does not feel like she has broken any bones.

Functional status prior to injury: She had full range of movement and full sensation in her right arm, wrist, and hand prior to the injury.

Medical History: Patient denies any allergies, diabetes, renal disease, cardiac and vascular diseases, and no bleeding disorder. She is a healthy non-smoker, and her only medication is an OCP.

Tetanus Status: She is up-to-date with her immunizations and her last tetanus shot was 2 years ago.

C- Perform a Physical Exam:

Patient is a well-looking 28 year old female with no signs of distress. She is alert and oriented to person, place, and time. She has a bandage on her right forearm that has dried blood on it. She denies any numbness or tingling in her hand. There is no obvious deformity of the arm.

Remove bandage and assess wound: Patient has a 6 cm rounded laceration with the wound extending from the mid-wrist on the volar side to Lister’s tubercle on the dorsal side. It looks like you can see some tendons and muscle at the wound base, but they do not look injured. There is no sign of glass or other foreign bodies, no dead tissue, and the wound bed appears bloody. It has a slow stream of blood running out of it. The surround skin is pink and appears undamaged.

Assess for neurovascular compromise ^3,4  : The wrist anatomy is complex and it is important to consider the underlying anatomy when deciding on how to test for injury. Also compare to the patients “normal” other side.

Test for motor function: patient is able to fully extend, flex, and deviate the wrist to both ulnar and radial sides. She is able to flex, extend, abduct, and adduct her thumb, and has no trouble with opposition. She has flexion at the PIP and DIP joints from D2 to D5. She is able to fully extend her fingers and perform abduction as well. Her strength is 5/5 for these movements as well.

Test for sensation: Patient has sensation to light-touch and pin-prick over her thenar eminence, distal aspect and dorsal aspect (proximal to PIP) of D2, D3, and radial half of D3 (testing for intact median nerve). As well as sensation over the radial aspect of the dorsal hand (Radial Nerve). With this injury you should not expect the ulnar nerve to be damaged, but you’re a studious clerk and testing reveals intact sensation.

Test for vascular compromise: You do not notice any pulsatile aspect to the bleeding, her skin is pink, warm, and has <3 seconds of capillary refill. You palpate strong radial pulses and are reassured that she has not injured this artery.

With this examination you are reassured that she has not injured any underlying structures (tendons, nerves, muscles, and vasculature). You tell the patient that despite a large cut, she is lucky that no serious damage was done.

D- Obtain Pain Control: Either local or regional anesthesia.

Luckily, you just finished your plastic surgery rotation and had plenty of experience drawing up local anesthetic. You also learned how to inject a wound while trying to minimize the patients pain. You were told to ALWAYS USE EPI and ALWAYS USE BICARB in your anesthetic solution.⁵ You draw up one 10 ml solutions (or 100mg) of Lidocaine 1% with epinephrine 1:100,000 buffered with 1 ml bicarbonate (1:10 ratio of bicarb to lidocaine). Maximum dose being 7mg/kg or 420 mg for this patient. You’re wondering if you might need more and realize that you could be getting close to the patient maximum dose; however, you remembered you could always dilute your solutions to double the amount of syringes and still have effective analgesia.^5,6 You use a smaller gauge needle (27 or 30 gauge) as this helps to reduce the pain experienced by the patient.⁵ You let the patient sit for a while so the analgesia will be effective.

ED Rounds – EM and Hand Surgery – Dr Don Lalonde

Regional anesthesia of the hand

E – Irrigation and Cleansing:

You irrigation the wound with copious amounts of tap water (or saline). Again, you notice no foreign bodies or signs of infection. You position the patient lying down in bed and cleanse the skin around the wound with chlorhexidine swabs to prep the surface for wound closure.^1,3,7,8

Note: Debridement of jagged, dead, or highly contaminated tissue may be necessary in order to promote wound healing and provide an optimal surface for closure and cosmetic effect.³

F- Wound Closure with Sutures:

When you were gathering your supplies you realized there were many options for sutures, so you decided to ask your attending. They recommended a non-absorbable either 4-0 or 5-0 Nylon suture and to use a simple interrupted technique. You closed the wound and the edges approximated well. You, your patient, attending are all happy with the result. The patient is discharged with follow-up for suture removal in 7 days.

Wound Closure Resources

• https://teachmesurgery.com/skills/surgical/suturing/
• Laceration repair a practical approach – AAFP
• Advanced wound closure techniques

Useful Patient Information Reference from the ACS

Suture Types: To absorb or not to absorb?

Typical emergency department suture choice is a monofilament non-absorbable suture, this is due to ease of handling, knot security (does not easily break), and emergency texts report a lower rate of infections.^1,2,3 There is also the need for suture removal, which requires follow-up and a second look at how the wound is healing. Absorbable sutures are usually harder to handle and tying knots can be tricky due to ease of breaking, especially with smaller sized sutures. Much of the emergency texts cite an increase in rates of infection with absorbable sutures as a reason not to choose them. However, evidence suggests that there is no significant difference in rates of infections or clinical outcome.^9-12 Literature does point towards higher rates of tissue reactivity (inflammation associated with placing of suture) with absorbable sutures.¹² Really selection of sutures comes down to wound factors (location and tension requirements), patient factors (need for follow-up, compliance, etc.), as well as physician preference. See tables for types and recommended use.

References:

1. Busse, Brittany, and SpringerLink. Wound Management in Urgent Care. 1st Ed. 2016.. ed. Cham: Springer International : Imprint: Springer, 2016. Web.
2. Cydulka, Rita K. Tintinalli’s Emergency Medicine Manual. 8th ed. New York: McGraw-Hill Education, 2018. Print.
3. Reichman, Eric F. Reichman’s Emergency Medicine Procedures. McGraw Hill Professional, 2018.
4. Janis, Jeffrey E. Essentials of plastic surgery. CRC Press, 2014.
5. Strazar, A. Robert, Peter G. Leynes, and Donald H. Lalonde. “Minimizing the Pain of Local Anesthesia Injection.” Plastic and Reconstructive Surgery3 (2013): 675-84. Web.
6. Lalonde, Donald H. ““Hole-in-One” Local Anesthesia for Wide-Awake Carpal Tunnel Surgery.”Plastic and Reconstructive Surgery 5 (2010): 1642-644. Web.
7. Deboard, Ryan H, Dawn F Rondeau, Christopher S Kang, Alfredo Sabbaj, and John G Mcmanus. “Principles of Basic Wound Evaluation and Management in the Emergency Department.”Emergency Medicine Clinics of North America 1 (2007): 23-39. Web.
8. Forsch, Randall T. “Essentials of Skin Laceration Repair.” American Family Physician8 (2008): 945-51. Web.
9. Kharwadkar, N., S. Naique, and P.J.A Molitor. “Prospective Randomized Trial Comparing Absorbable and Non-absorbable Sutures in Open Carpal Tunnel Release.” Journal of Hand Surgery1 (2005): 92-95. Web.
10. Xu, Utku, Bin, Xu, Utku, Bo, Wang, Utku, Liwei, Chen, Utku, Chunqiu, Yilmaz, Utku, Tonguç, Zheng, Utku, Wenyan, and He, Utku, Bin. “Absorbable Versus Nonabsorbable Sutures for Skin Closure: A Meta-analysis of Randomized Controlled Trials.” Annals of Plastic Surgery5 (2016): 598-606. Web.
11. Sheik-Ali, Sharaf, and Wilfried Guets. “Absorbable vs Non Absorbable Sutures for Wound Closure. Systematic Review of Systematic Reviews.” IDEAS Working Paper Series from RePEc(2018): IDEAS Working Paper Series from RePEc, 2018. Web.
12. deLemos, D. (2018). Closure of minor skin wounds with sutures. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Retrieved July 3^rd, 2020. Source