Wounds and Lacerations - E-Book , livre ebook

Wounds and Lacerations
Emergency Care and Closure
F OURTH E DITION

Alexander T. Trott, MD
Professor of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
Saunders
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
WOUNDS AND LACERATIONS: EMERGENCY CARE AND CLOSURE, FOURTH EDITION ISBN: 978-0-323-07418-6
Copyright © 2012 by Saunders, an imprint of Elsevier Inc.
Copyright © 2005, 1997, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions .
This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
Library of Congress Cataloging-in-Publication Data
Trott, Alexander.
   Wounds and lacerations : emergency care and closure / Alexander T. Trott.—4th ed.
       p. ; cm.
   Includes bibliographical references and index.
   ISBN 978-0-323-07418-6 (hardcover : alk. paper)
   I. Title.
   [DNLM: 1. Wounds and Injuries—therapy. 2. Emergencies. 3. Suture Techniques. 4. Wound Healing. WO 700]
   617.1—dc23
               2011039845
Senior Content Strategist: Stefanie Jewell-Thomas
Content Development Specialist: Roxanne Halpine Ward
Publishing Services Manager: Patricia Tannian
Senior Project Manager: Kristine Feeherty
Design Direction: Steven Stave
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
To Jennifer, who was the original inspiration for the text, and for her endless patience and support
Editorial Coordinator

Shawn Ryan, MD, MBA
Assistant Professor, Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
Contributors

Gregg A. DiGiulio, MD
Associate Professor, Department of Pediatrics, Northeast Ohio Medical University, Rootstown, Ohio;
Attending Physician, Division of Emergency Medicine, Department of Pediatrics, Akron Children’s Hospital, Akron, Ohio

Javier A. Gonzalez del Rey, MD, MEd
Professor of Clinical Pediatrics, Department of Pediatrics, University of Cincinnati College of Medicine;
Director, Pediatric Residency Training Programs, Associate Director, Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio

Carolyn K. Holland, MD, MEd
Assistant Professor of Clinical Pediatrics and Emergency Medicine, Pediatrics and Emergency Medicine, University of Cincinnati College of Medicine;
Attending Physician, Department of Pediatrics, Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center;
Attending Physician, Department of Emergency Medicine, University Hospital, Cincinnati, Ohio
Preface
There are certain clinical skills basic to most practitioners: physicians, mid-level providers, nurses, wound care technicians, and medics. The care of surface injury and lacerations is one of them. Until the 1980s, suturing and other wound care procedures were taught at the bedside from one generation to the next. “Watch one, do one, teach one,” was a common refrain heard by young students trying to glean knowledge that would give them the skills to clean, suture, and dress wounds.
With the growth of emergency medicine and its acceptance as a specialty came a rapid growth of textbooks and educational materials that organized and presented didactic material necessary for the students and residents training in emergency care. Wounds and Lacerations, now in its fourth edition, represents an effort to provide students and practitioners with a ready source of information and recommendations to care for a patient with surface injuries. All care recommendations are the product of the available evidence, science and literature, to back them up. In cases where no science exists, consensus of experienced practitioners and the authors is offered as support. The success of previous editions lends credence to this approach, as well as the straightforward and uncomplicated manner in which the content is presented.
The reader of this new edition will find a change in format and content. Each chapter will be introduced with the Key Practice Points covered in that chapter. The text has been edited for greater clarity, and more lists and tables are used for quick and easy reference. Each chapter has been updated with the most recent available science and literature. Many illustrations have been updated, and new ones have been added. There have been significant changes in several content areas. The use of absorbable sutures on the face and hand is now a common practice. The cosmetic outcome is the same as for nonabsorbable sutures, and visits for suture removal can be eliminated. The emergence of community-associated methicillin-resistant Staphylococcus aureus is a new challenge. The use of emergency department ultrasound to find and remove foreign bodies is becoming more common. Recommendations for tetanus and rabies prophylaxis have undergone significant changes.
Although this text originated from practices in the emergency department, it is clear that wound care crosses many specialties and disciplines. Wound care can take place in emergency departments, clinics, practitioners’ offices, aid stations, and even in the field. Where this text is used and who uses it have no limits. If it can benefit one patient, under whatever circumstance, then it is a success.

Alexander T. Trott, MD
Table of Contents
Cover
Copyright
Dedication
Editorial Coordinator
Contributors
Preface
Chapter 1: Emergency Wound Care: An Overview
Goals of Wound Closure
Patient Expectations
Risks of Wound Care
Chapter 2: Patient Evaluation and Wound Assessment
Initial Steps
Wound Evaluation and Documentation
Wound History
Past/Social History
Physical Examination
Procedure
Disposition
Chapter 3: Anatomy of Wound Repair
Anatomy of the Skin and Fascia
Skin Tension Lines
Alterations of Skin Anatomy
Chapter 4: Wound Healing and Cosmetic Outcome
Normal Wound Healing
Factors Affecting Cosmetic Outcome (Box 4-1)
Technical Factors
Anatomic Factors
Associated Conditions and Diseases
Drugs
Suture Marks
Keloid and Hypertrophic Scars
Scar Management and Revision
Chapter 5: Wound Care and the Pediatric Patient
General Approach and Calming Techniques
Restraint for Wound Care
Pediatric Patient Sedation
Local Anesthetic Techniques
Choice of Closure Materials
Special Considerations for Different Anatomic Sites
Abscess Drainage
Wound Aftercare
Chapter 6: Infiltration and Nerve Block Anesthesia
Local Anesthetics: Practical Points
Anesthetic Solutions
Toxicity of Local Anesthetics
Allergy to Local Anesthetics
Reducing the Pain of Local Anesthesia
Adult Patient Sedation
Anesthesia Techniques
Chapter 7: Wound Cleansing and Irrigation
Wound Cleansing Solutions
Preparation for Wound Cleansing
Cleansing Setup and Procedures
Chapter 8: Instruments, Suture Materials, and Closure Choices
Basic Instruments and Handling
Suture Materials
Needle Types
Chapter 9: Decisions before Closure: Timing, Débridement, and Consultation
Timing of Closure
Wound Exploration
Hemostasis
Tissue Débridement and Excision
Surgical Drains
Immediate Antibiotic Therapy
Guidelines for Consultation
Chapter 10: Basic Laceration Repair: Principles and Techniques
Definition of Terms
Basic Knot-Tying Techniques
Principles of Wound Closure
Chapter 11: Complex Skin Wounds: Advanced Repair Techniques
Running Suture Closure
Beveled (Skived) Wounds
Pull-Out Subcuticular Closure
Subcuticular Running Closure
Corner Stitch
Partial Avulsion, Flap Wounds
Geographic Lacerations
Complete Avulsions
Dog-Ear Deformities
Parallel Lacerations
Thin-Edge, Thick-Edge Wounds
Laceration in an Abrasion
Chapter 12: Special Anatomic Sites
Scalp
Forehead
Eyebrow and Eyelid
Cheek or Zygomatic Area
Nasal Structures
Ear
Lips
Oral Cavity
Perineum
Knee
Lowe