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Chapter 94 WOUND MANAGEMENT648
disturbances, including visual aura or scotoma, tinnitus, perioral tingling, or a metallic taste in
the mouth. Slurred speech, disorientation, muscle twitching, and finally seizures may follow.
The cardiovascular effects are manifested by hypotension, bradycardia, and prolonged
electrocardiogram (ECG) intervals. In severe toxicity, the end result is seizures, coma, and
cardiorespiratory arrest.
12. What can I use to anesthetize a patient who is allergic to amide and ester
anesthetics?
Subdermal diphenhydramine may be injected locally to obtain short-acting analgesia. Prepare a
0.5 to 1.0% solution by diluting 1 mL of 50 mg/mL diphenhydramine into 5 to 10 mL of saline.
The anesthetic effect may take several minutes to become evident. Do not exceed a total dose
of 50 mg in adults or 1 mg/kg in children. The patient may become drowsy after the injection.
13. What are the contraindications to epinephrine as an adjunct to lidocaine and
bupivacaine?
Anesthetics with epinephrine should not be used on digits, the pinna, circumferentially around the
penis, or in areas with poor or marginal blood supply, such as flap wounds of the anterior pretibial
area. Epinephrine decreases resistance to infection because of its potent vasoconstrictor effect. In
areas of the body such as the scalp and face, the vasoconstriction and resulting hemostasis aid in
the exploration and repair of the wound and do not seem to increase wound infection.
14. What is LET (LAT)?
A topical anesthetic that consists of a mixture of lidocaine (4%), epinephrine (adrenaline)
1:1000, and tetracaine (0.5%). LET has been shown to be efficacious for wound anesthesia
and is the topical agent of choice. It has a good margin of safety. For optimal effect it should
be placed directly into the wound.
15. What are the contraindications to LET?
They are the same as for lidocaine or bupivacaine with epinephrine.
16. When do I use procedural sedation?
Procedural sedation is a pharmacologic means of lowering the level of consciousness to allow
procedures to be performed easily with optimal results. See Chapter 66.
17. What is a contaminated wound?
Any wound that has a high inoculum of bacteria. Some examples are:
n
Full-thickness bites
n
Wounds of the perineum or axilla where there is normally a high skin flora count
n
Wounds that are exposed to contaminated water, such as from ponds, lakes, or coral reefs
Anesthetic Class Maximum Dose Duration
Lidocaine Amide 4.5 mg/kg 1–2 hours
Lidocaine with epinephrine Amide 7 mg/kg 2–4 hours
Bupivacaine Amide 2 mg/kg 4–8 hours
Bupivacaine with epinephrine Amide 3 mg/kg 8–16 hours
Procaine Ester 7 mg/kg 15–45 minutes
Procaine with epinephrine Ester 9 mg/kg 30–60 minutes
TABLE 94–2 MAXIMUM DOSE AND DURATION OF ACTION OF ANESTHETICS
Chapter 94 WOUND MANAGEMENT 649
18. List factors that contribute to wound infection.
n
Wound age
n
Presence of foreign material
n
Amount of devitalized tissue
n
Presence of bacterial contamination
n
Advanced patient age
n
Ability of the host to mount an adequate immune response
19. Is a dirty wound the same as a contaminated wound?
No. Road rash, resulting from road gravel, has a low bacterial count. In contrast, wounds that
occur in a barnyard or are exposed to soil contaminated with fecal material have a high
bacterial count and are contaminated.
20. What causes tattooing?
The retention of foreign material and incorporation of it in the dermis during the healing
process. To prevent this cosmetic complication, all foreign material and dirt must be removed
through proper débridement, scrubbing, and irrigation at the time of the initial patient
encounter. A stiff brush, such as a toothbrush, and soap are useful to remove dirt and asphalt
embedded in the dermis.
21. How do I treat road rash?
Anesthetize the area with viscous lidocaine and circumferential or field block anesthesia.
Remove all foreign bodies with the methods described previously. Consider dressing with
silver sulfadiazine, which greatly reduces the pain and may obviate the need for potent oral
analgesics for deep, extensive, painful abrasions.
22. When do I get an X-ray?
Radiographs are useful to search for a foreign body or to look for an associated fracture. Obtain
a radiograph if the history is suspicious for a foreign body (e.g., broken glass) and the wound
penetrates muscle fascia or the entire depth of the wound cannot be visualized. In the case of
some bite wounds or lip lacerations with broken or avulsed teeth, radiographs should be
considered to search for teeth. With severe pain or structural instability, radiographs may reveal
an underlying open fracture, which necessitates an orthopedic consultation in most cases.
23. Which types of foreign bodies found in wounds are visible on radiographs?
Glass, metal, and gravel. In general, glass larger than 2 mm and gravel larger than 1 mm can
be seen on radiographs. Foreign bodies that are radiolucent (not visible on radiographs)
include wood, plastics, and some aluminum products.
24. What is the best method for hair removal?
Clipping or cutting hair with scissors as opposed to shaving has been shown to result in lower
wound bacterial counts and decreased rates of infection.
25. Define the three different types of wound closure.
n
Primary closure is closure of wound margins with sutures, staples, glues, or adhesive
tapes within 24 hours of the time of injury.
n
Delayed primary closure is closure of a wound 3-5 days after wounding to decrease the
risk of infection.
n
Secondary closure, or healing by secondary intention, is allowing a wound to heal by
granulation without mechanical approximation of the wound margins.
26. Which wounds should be closed primarily?
Any clean (not initially contaminated) wound if it is less than 6 to 8 hours old and is located
anywhere on the body except for the face and scalp, which may be closed primarily up to
24 hours because of the rich vascular supply and resistance to infection.
Chapter 94 WOUND MANAGEMENT650
27. When should secondary closure be used?
For contaminated wounds that penetrate deeply into tissue and cannot be irrigated adequately
before closure. Examples of such wounds are puncture wounds of the sole of the foot or palm
of the hand and stab wounds that penetrate into subcutaneous tissue and muscle.
28. When should delayed primary closure be used?
It should be strongly considered for all contaminated wounds that are gaping or have
significant amounts of tension. It decreases the risk of infection, optimizes the cosmetic
result, and accelerates the healing process.
29. How is a wound prepared for delayed primary closure?
The wound should be examined thoroughly, débrided, and irrigated. Hemorrhage should be
controlled. A fine layer of mesh gauze should be laid in the wound; the wound should be
packed open and followed closely. At 3 to 5 days, if there is no purulent drainage or wound-
margin erythema, the wound may be closed in the same fashion as if it were being closed
primarily.
30. What is the most important step when closing a lip laceration through the
vermilion border?
Placement of the first suture at the vermilion border. Use nonabsorbable suture to close the
edges of the vermilion border. Be sure to line up the edges precisely. Failure to do so will
result in a visible cosmetic defect. The remainder of the lip should be closed with absorbable
suture. The skin should be closed with nonabsorbable suture.
31. When are surgical staples indicated?
To reapproximate linear lacerations that do not involve cosmetically sensitive areas such as
the face. Two approaches are commonly employed. One approach involves two operators with
one everting both wound edges with forceps while the other staples the wound together. If
only one operator is available, the wound edges should be aligned and one edge everted with
forceps in one hand while stapling with the other. Staples work best in wounds that are
perpendicular, that is, 90 degrees to the surface, rather than with shelving angular lacerations
because these tend to overlap.
32. What is surgical glue, and how is it used?
Surgical glue is 2-0ctyl cyanoacrylate (Dermabond) is a polymer currently being used as an
alternative for wound repair. Cyanoacrylate acts rapidly, polymerizing within 30 seconds at
room air. It is best used for linear lacerations under low tension and may replace 5-0 or
6-0 sutures. The wound can be held together manually, and the cyanoacrylate can be painted
over the wound in three to four coats to ensure adequate closure. Be careful not to apply any
adhesive within the wound because this will impede healing. The adhesive sloughs off in 7 to
10 days. Do not use antibiotic ointment or any other type of ointment on the wound because it
destroys the adhesive bond.
33. How do I remove tissue adhesive?
First, avoid getting tissue adhesive into undesirable areas by applying protective covering and
petroleum jelly to areas surrounding the wound. Apply light coats of the adhesive and quickly
wipe off excess fluid. You have about 15 seconds before the adhesive dries. If the adhesive
dries on an undesirable area (e.g., eyelid glued shut), the bond may be loosened with
petroleum jelly or antibiotic ointment.
34. Summarize the advantages and disadvantages of the available techniques for
wound closure.
See Table 94-3.
Chapter 94 WOUND MANAGEMENT 651
CT, computed tomography; MRI, magnetic resonance imaging.
From Singer AJ, Hollander JE, Quinn JV: Evaluation and management of traumatic lacerations. N Engl J
Med 337:1142–1148. Copyright ©1997 Massachusetts Medical Society. All rights reserved.
Technique Advantages Disadvantages
Sutures Time-honored method
Meticulous closure
Greatest tensile strength
Lowest dehiscence rate
Removal required
Anesthesia required
Greatest tissue reactivity
Slowness of application
Staples Rapidity of application
Low tissue reactivity
Low cost
Less meticulous closure than with
sutures
May interfere with CT and MRI
May result in uneven wound edges
Tissue
adhesives
Rapidity of application
Patient comfort
Resistance to bacterial
growth
No need for removal
Sometimes no need for
needle stick
Lower tensile strength than sutures
Dehiscence over high-tension areas
(joints)
Wound healing inhibited if placed in the
wound
High cost
Surgical tapes Least tissue reactivity
Lowest infection rates
Rapidity of application
Patient comfort
Low cost
Lower tensile strength than sutures
Highest rate of dehiscence
Cannot be used in hairy areas
Must remain dry
35. Which sutures are used, how is the wound repaired, and when do I remove
the sutures?
See Table 94-4.
36. How are bites treated?
See Figure 94-1.
37. What should be included in all follow-up instructions?
Instructions on local wound care, signs of infection, and time of suture removal. Antimicrobial
ointment may be applied to decrease the risk of infection; however, when tissue adhesives have
been used, ointments dissolve the adhesive and may cause separation of the wound. Sunlight
should be avoided, and sunscreen should be used to help minimize hyperpigmentation and
scarring. Inform patients that all wounds will heal with a scar, all wounds may get infected, and
all wounds may have retained foreign material.
TABLE 94–3. ADVANTAGES AND DISADVANTAGES OF WOUND CLOSURE TECHNIQUES
Chapter 94 WOUND MANAGEMENT652652
SA, synthetic absorbable sutures such as Vicryl and Dexon; SC, subcutaneous.
From Markovchick V: Soft tissue injury and wound repair. In Reisdorff EJ, Roberts MR, Wiegenstein JG,
editors: Pediatric emergency medicine, Philadelphia, 1993, WB Saunders, pp 899–908.
Location Suture Material
Technique of Closure
and Dressing
Suture
Removal
Scalp 3–0 or 4–0 nylon or
polypropylene
Interrupted in galea; single tight layer in
scalp; horizontal mattress if bleeding not
well controlled by simple sutures
7–10 days
Pinna
(ear)
6–0 nylon or 5–0
SA in perichon-
drium
Close perichondrium with 5–0 SA
interrupted; close skin with 6–0 nylon
interrupted; stint dressing
4–6 days
Eyebrow 4–0 or 5–0 SA and
6–0 nylon
Layered closure 4–5 days
Eyelid 6–0 nylon or silk Single layer simple or horizontal mattress 5-6 days
Lip 4–0 silk or SA (mu-
cosa); 5–0 SA (SC,
muscle); 6–0 (skin);
4–0 SA
Three layers (mucosa, muscle, skin) if
through and through, otherwise two layers
5-6 days
Oral
cavity
4–0 SA Simple interrupted or horizontal mattress:
layered closure if the muscularis of the
tongue is involved
7–8 days or
allow to
dissolve
Face 4–0 or 5–0 SA (SC);
6–0 nylon (skin)
If full-thickness laceration, layered closure
desirable
5-6 days
Neck 4–0 SA (SC); 5–0
nylon (skin)
Two-layered closure for best cosmetic
results
5-6 days
Trunk 4–0 SA (Sq, fat);
4–0 or 5–0 nylon
(skin)
Single or layered closure 7–12 days
Extremity 3–0 or 4–0 SA (SC,
fat, muscle); 4–0 or
5–0 nylon (skin)
Single or layered closure is adequate,
although a layered or running Sq closure
may give a better cosmetic result; apply a
splint if the wound is over a joint
7–14 days
Hands
and feet
4–0 or 5–0 nylon Single-layer closure only with simple or
interrupted horizontal mattress suture, at
least 5 mm from cut wound edges; hori-
zontal mattress sutures should be used if
there is much tension on wound edges;
apply splint if wound is over a joint
7–12 days
Nailbeds 5–0 SA Gentle, meticulous placement to obtain
even edges. Replace nail under cuticle
Allow to
dissolve
TABLE 94–4 USE OF SUTURES FOR WOUND REPAIR
Chapter 94 WOUND MANAGEMENT 653
38. How do I remember the direction of
the lines of skin tension?
You don’t, unless you have a photographic
memory. Refer to Figures 94-2 and 94-3.
39. Are there any controversies in wound
care?
The primary controversy relates to the use
of prophylactic antibiotics. Their use is
widespread and has developed with little
scientific support. In general, the use of
prophylactic antibiotics is not warranted in
the normal host. Antibiotic therapy is
indicated in patients with soft tissue
wounds who are prone to infective
endocarditis. Antibiotics may be indicated
when the risk for infection is high, including
wounds of the distal foot; contaminated
wounds; wounds in which there has been a
delay in irrigation and débridement; and
wounds that contain fecal material, pus,
saliva, or vaginal secretions. Prophylactic
antibiotic use should never replace proper
wound decontamination. To meet the
standard of care, as perceived by many, and
to decrease cost to the patient, generic
antibiotics should be used.
Figure 94-1. Algorithm for treatment of bites.
Figure 94-2. Direction of the lines of
skin tension for the face. (From Marx J,
Hockberger R, Well R, et al, editors:
Rosen’s emergency medicine: concepts and
clinical practice, ed 5, Philadelphia, 2002,
Mosby, p 738.)
Chapter 94 WOUND MANAGEMENT654
Figure 94-3. Direction of the lines of skin tension for the body. (From
Marx J, Hockberger R, Well R, et al, editors: Rosen’s emergency
medicine: concepts and clinical practice, ed 5, Philadelphia, 2002,
Mosby p 739.)
KEY POINTS: WOUND MANAGEMENT
1. Use a tourniquet, if necessary, on extremities to adequately examine and repair the wound.
2. Irrigation pressure must be at least 8 psi.
3. Wounds may be irrigated with tap water or sterile saline.
4. It soap is used, irrigation should follow.
5. A stiff brush (toothbrush) will remove ground-in dirt.
Chapter 94 WOUND MANAGEMENT 655
BIBLIOGRAPHY
1. Bansal BC, Wiebe RA, Perkins SD, et al: Tap water for irrigation of lacerations. Am J Emerg Med 20:469–472,
2002.
2. Dulecki M, Pieper B: Irrigating simple acute traumatic wounds: a review of the current literature. J Emerg
Nurs 31(2):156–,60, 2005.
3. Hollander JE, Singer AJ: Wound management. In Harwood-Nuss AL, Wolfson AB, editors: The clinical practice
of emergency medicine, ed 3, Philadelphia, 2005, Lippincott Williams & Wilkins, pp 912–921.
4. Hollander JE, Singer AJ, Valentine SM, et al: Risk factors for infection in patients with traumatic lacerations.
Acad Emerg Med 8:716–720, 2001.
5. Howell JM, Chishholm CD: Wound care. Emerg Med Clin North Am 15:417–425, 1997.
6. Markovchick V: Soft tissue injuries. In Barkin R, Rosen P, editors: Emergency pediatrics: a guide to
ambulatory care. Philadelphia, 2003, Mosby, pp 505–514.
7. Markovchick V: Soft tissue injury wound repair. In Reisdorf EJ, Roberts MR, Wiegenstein JG, editors:
Pediatric emergency medicine. Philadelphia, 1993, W. B. Saunders, pp 899–908.
8. Markovchick V: Suture materials and mechanical after care. Emerg Med Clin North Am 10:673–689, 1992.
9. Moscati RM, Reardon RF, Lerner EB, et al: Wound irrigation with tap water. Acad Emerg Med 5:1076–1080, 1998.
10. Moscati R, Mayrose J, Fincher L, et al: Comparison of normal saline with tap water for wound irrigation.
Am J Emerg Med 16:379–381, 1998.
11. Schilling CG, Bank DE, Borchert BA, et al: Tetracaine, epinephrine (adrenaline), and cocaine (TAC) versus lidocaine,
epinephrine, and tetracaine (LET) for anesthesia of lacerations in children. Ann Emerg Med 25:203–208, 1995.
12. Simon B, Hern HJ: Wound management principles. In Marx J, Hockberger R, Well R, et al editors: Rosen’s
emergency medicine, 6th ed. Philadelphia, Mosby, 2006, pp 842-858.
13. Singer AJ, Hollander JE, Quinn JV: Evaluation and management of traumatic lacerations. N Engl J Med
337:1142–1148, 1997.
14. Wilson JL, Kocurek K, Doty BJ: A systematic approach to laceration repair: tricks to ensure the desired
cosmetic result. Postgrad Med 107:77–88, 2000.
657
ACUTE PSYCHOSIS
CHAPTER 95
Manish Amin, DO
XVII. BEHAVIORAL EMERGENCIES
1. What is psychosis?
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), the term
psychosis “has historically received a number of different definitions, none of which has
achieved universal acceptance. The narrowest definition of psychosis is restricted to delusions
or prominent hallucinations, with the hallucinations occurring in the absence of insight into
their pathological nature.”
2. What are delusions?
“Delusions are erroneous beliefs that usually involve a misinterpretation of perceptions or
experiences. Their content may include a variety of themes (e.g., persecutory, referential,
somatic, religious, or grandiose). Persecutory delusions are most common; the person
believes he or she is being tormented, followed, tricked, spied on, or ridiculed. Referential
delusions are also common; the person believes that certain gestures, comments, passages
from books, newspapers, song lyrics, or other environmental cues are specifically directed at
him or her.”
3. What are hallucinations?
“Hallucinations are sensory perceptions without external stimulation. Hallucinations may occur
in any sensory modality (e.g., auditory, visual, olfactory, gustatory, and tactile). Auditory
hallucinations are by far the most common.”
4. How does a patient in a psychotic state typically present to the ED?
Patients who are in a psychotic state may act strangely (i.e., mannerisms, posturing),
dress bizarrely, respond to hallucinations, harbor false and delusional beliefs, and
consistently confuse the reality of events. They are frequently impulsive and in constant
danger of acting on distorted perceptions or delusional ideas resulting in unintentional
injury or death. Clarity of oneself and the environment is consistently blurred. The patient
is unable to discriminate the stimuli that he or she perceives. Thinking is disorganized and
incoherent, as evidenced from the patient’s speech. Memory is impaired in registration,
retention, and recall. Orientation may be impaired, especially for time. Psychomotor
behavior may be hypoactive or hyperactive. Emotions can range from apathy and
depression to fear and rage.
5. How should priorities be set when I first encounter a psychotic patient?
n
Assess the ABCs (airway, breathing, circulation) if necessary.
n
Observe (quickly assess the patient’s impulse control and tendency to physically act out).
n
Control and manage psychotic behavior, if necessary.
n
Obtain a history (gather information from everyone who has been involved with the
patient).
n
Differentiate between organic and functional causes of psychosis.
n
Do a complete physical examination.
n
Obtain laboratory tests as deemed appropriate.
n
Obtain a psychiatric consultation and disposition.