Author: Zack (Page 7 of 9)

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Evaluate 5 important structures when evaluating gunshot wounds in an extremity.

Blood Vessel Injuries

• 3 Categories
  • Hard-Signers
    • Mnemonic: HARD Bruit
      • Hypotension
      • Arterial/pulsatile bleeding
      • Rapidly expanding hematoma
      • Deficits (pulse)
      • Audible BRUIT/thrill
    • These patients likely need OR
  • Soft-Signers
    • Significant vascular oozing/bleeding
    • Large hematoma
      • These patients need to be screened with ABI (ankle brachial index)
        • ABI <0.9 or asymmetry between extremities is concerning for vascular injury
      • If abnormal, obtain a CTA
  • No-Signers
    • No additional management for vascular injury required

Nerve Injuries

• Relatively rare
• Document neuro exam in the extremity
• Consult if abnormal

Bone Injuries

• Relatively common
• Diagnosed by x-ray
• Consult orthopedics for fracture

Soft Tissue Injury

• Be sure to count/document number of holes
• Typically do not need laceration repair unless cosmetic area
• Don’t miss compartment syndrome
  • Mnemonic: “P’s”
    • Pain out of Proportion
    • Pain with Passive range of motion
    • Paresthesias
    • Pallor
    • Paralysis
    • Poikilothermia

The Bullet: What To Do With It?

• The bullet is almost never removed, unless…
  • Very superficial/cosmetic and easy to remove
  • In a joint

Additional Reading

• NBME Shelf Review Part 2- Trauma (EM Clerkship)

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Step 1: Pain Control

• Local anesthesia
  • Most common agent is lidocaine (frequently already in laceration repair kits)
  • Inject through wound edges (not through epidermis)
  • This decreases pain
• Alternative is digital/regional nerve block

Step 2: Irrigation

• Laceration repair is not a sterile procedure
• Copious irrigation is the best method to decrease chance of wound infection
  • Faucet/sink vs saline

Step 3: Alternative Wound Closure Techniques

• Dermabond/Tissue Adhesive
  • Works best on easily approximated wound edges and little tension
  • Commonly used in pediatrics and geriatrics
• Staples
  • Sometimes leaves a poor cosmetic outcome
  • Commonly used for scalp wounds
  • Rapidly stops bleeding
  • Quickest and easiest closure method to perform

Step 4: Choose a Suture Type

• Absorbable (Gut, Monocryl)
  • Pros: Patient doesn’t need to return for removal
  • Cons: Loses tensile strength
• Non-Absorbable (Prolene)
  • Pros: Good cosmetic outcomes, easy to see (bright blue)
  • Cons: Patient must have them removed

Step 5: Repair the Wound

• Gently approximate wound edges
  • You are not trying to “seal” the wound closed
  • Primary goal is to improve cosmetic outcome
• Keep it simple
  • Simple interrupted sutures
  • Instrument tie

Additional Reading

• Laceration Evaluation (EM Clerkship)
• Wound Closure for the Emergency Practitioner (LacerationRepair)

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Lacerations are the single best opportunity to demonstrate your procedural skills during your clerkship!!!

To Close or Not To Close?

• Closing a wound with sutures, etc = Healing by “primary intention”
  • INCREASES risk of infection but DECREASES scar
• Leaving a wound open = Healing by “secondary intention”
  • DECREASES risk of infection but INCREASES scar

Step 1: History

• Does patient have comorbidities that increase risk of infection/poor healing?
  • Diabetes
  • Renal Failure
  • Obesity
  • Smoking
  • Immunosuppression
• How long since injury happened?
• Any concern for foreign body?

Step 2: Identify Tetanus Status

• Has patient EVER been immunized against tetanus?
• Has it been >5 years since last tetanus shot?

Step 3: Tetanus Prophylaxis

• Give tetanus booster (Tdap) if >5 years since last tetanus shot
• Give tetanus immunoglobulin (IG) if patient has never had tetanus immunization

Step 4: Give Specific, Objective Description of Laceration

• EXACT length
  • Must use a ruler
  • Most important BILLING categories
    • 2.5 cm or less
    • 2.6 cm to 7.5 cm
    • 7.6 cm to 12.5 cm
• Description
  • Shape
    • Linear
    • Stellate
    • Flap
  • Depth
    • Superficial
    • Muscle
    • Bone
• Neurovascular exam
  • Sensation
  • Motor
  • Cap refill

Step 5: Rule Out Foreign Body

• Consider X-Ray
  • Not all foreign bodies will show up on x-ray
    • Especially organic material, clothing, etc
• Consider bedside ultrasound
  • (You are not expected to know how to do this, only to consider this)

Additional Reading

• Laceration Repair (EM Clerkship)
• Wound Closure for the Emergency Practitioner (LacerationRepair)