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    • Advanced Emergency Nursing Journal Vol. 32, No. 4, pp. 360–372 Copyright c 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Wound Care and Laceration Repair for Nurse Practitioners in Emergency Care Part I Lt. Col. Kathleen Flarity, ARNP, PhD, CEN, CFRN, FAEN K. Sue Hoyt, PhD, RN, FNP-BC, CEN, FAEN, FAANP Abstract This is part one of a 2-part series on wound care and laceration repair for advanced practice nurses. The purpose of this article is to outline the phases and categories of wound healing and to discuss factors that affect wound healing. This article also describes an approach for systematic wound management so as to decrease the risk for infection of nonsurgical wounds. Patient assessment, special circumstances involving underlying structures, and foreign bodies are also discussed herein. Patient preparation, including wound cleansing, irrigation, scrubbing, and debridement are also cov- ered along with anesthetic and analgesic tips and techniques for the advanced practice nurses in emergency care. Key words: laceration repair, suturing, wound anesthesia, wound care, wound closure, wound repair A CUTE TRAUMATIC WOUND MAN- AGEMENT is one of the most common procedures performed in the practice of emergency medicine (Emergency Nurses WOUND HEALING Understanding wound healing is an impor- tant aspect in the care of patients with lac- erations. There are phases of wound healing, Association, 2008; Roberts, 2010). The treat- ment goals for advanced practice nurses categories of wound healing, and factors af- working in emergency care settings are to pro- fecting wound healing. vide optimum care through the prevention of infection and the restoration of wound ap- Phases of Wound Healing pearance and function. Wound healing can be divided into the three phases: (1) Phase I is known as the hemostatic/inflammatory phase; (2) Phase II is called the proliferative phase; and (3) Phase Author Affiliations: 34th Aeromedical Evacuation Squadron Peterson AFB and Memorial Health System, III is named the remodeling phase (Table 1). Colorado Springs, Colorado (Lt. Col. Flarity); and St. Phase I: hemostatic/inflammatory. In Mary Medical Center, Long Beach and El Cajon, Cali- phase I, there is blood vessel disruption with fornia (Dr Hoyt). extravasation of blood constituents. Reflex The authors have no conflict of interest. vasoconstriction also occurs at this time re- Corresponding Author: Lt. Col. Kathleen Flarity, ARNP, PhD, CEN, CFRN, FAEN, Memorial Health System, ducing blood loss. Platelet aggregation and Colorado Springs, CO 80909 (KflarityR@aol.com). the formation of a platelet plug along with 360Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
    • October–December 2010 r Vol. 32, No. 4 Wound Care and Laceration Repair 361 Table 1. Phases of wound healing immediately, monocytes become activated macrophages, which produce growth factors and cytokines and scavenge nonviable tissue Phase I: INFLAMMATORY (2--5 days) and bacteria, whereas angiogenic growth Hemostasis: Vasoconstriction. factors stimulate neovascularization of the Platelet aggregation. wound bed. Thromboplastin makes clot. Phase II: proliferation. Phase II is Inflammation: the proliferative phase. In this phase, Vasodilation. macrophages recruit fibroblasts, creating a Phagocytosis. network of collagen fibers. When oxygen Phase II: PROLIFERATIVE and vitamin C are present, granulation tissue (5 days--3 weeks) forms. Fibroblasts create a collagen bed to Granulation: fill the defect and grow new capillaries. Fibroblasts lay down a bed of Myofibroblasts pull the wound edges closer collagen. together to decrease the size of the wound. Defect filled in. New capillaries at site of injury. New epithelium migrates from the intact Contraction: epidermis around the wound tissue. The Wound edges come together, duration of this phase is 2 days–3 weeks. reducing defect. Phase III: remodeling. In the final phase Epithelialization: of wound healing, organized form of collagen Crosses moist surface. gradually replaces the immature, soft, gelati- Cells move outward from site. nous collagen. The effect is to increase tensile Phase III: REMODELING strength of the healed wound. At this point, (3 weeks--2 years) the tissue is less than 80% as strong as the New collagen forms—increases tensile original tissue. The duration of this phase is strength. 3 weeks–2 years. Scar tissue forms (only 80% as strong as original tissue). Categories of Wound Healing Wound healing can be categorized as first (primary) intention, secondary intention, or platelets release growth factors that acti- delayed primary closure. Delayed primary vate monocytes and fibroblasts also occur. In closure is a combination of the first two ap- healthy individuals, the duration of phase I is proaches (Table 2). approximately 2–5 days. First (primary) intention. Primary heal- In phase I, tissue damage releases chem- ing occurs when a clean laceration or a surgi- ical mediators such as cytokines. Cytokines cal incision is closed primarily (e.g., sutures, initiate a complex interrelated process that steri-strips, adhesives). Surgical wound clo- causes hemostasis and begins the healing pro- sure facilitates the biological event of healing cess. Platelets aggregation occurs to stem by joining the wound edges. Wound closure bleeding to release serotonin. This activates directly apposes the tissue layers, minimiz- the coagulation cascade (fibrinogen into fib- ing new tissue formation, although remodel- rin) and stabilizes the platelet plug (Singer & ing occurs and tensile strength is achieved be- Hollander, 2003). tween the newly apposed edges. Closure can In addition, in this hemostatic/ serve both functional and aesthetic purposes. inflammatory period, prostaglandins and acti- It can eliminate dead space by approximat- vated complement cause vasodilation and ing the subcutaneous tissues. Primary closure increase capillary permeability (i.e., plasma may also minimize scar formation by care- leaks into tissue creating an inflammatory ful epidermal alignment, and it avoids a de- exudate). Neutrophils trap and kill bacteria pressed scar by precise eversion of skin edges.Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
    • 362 Advanced Emergency Nursing Journal Table 2. Categories of wound healing patient more complex procedures such as flap or skin graft reconstruction. Concave sur- faces, such as those presented by the auricle, Primary intention occiput, medial canthus, nasal alar crease, na- Closure of clean laceration/surgical incision. Closed with sutures, steri-strips, adhesives). solabial fold, and temple, heal well by sec- Functional and aesthetic purposes: ondary intention with minimal scarring. This Eliminates dead space by approximating approach is useful, especially in defects (ei- the subcutaneous tissues. ther superficial or deep) resulting from der- Minimizes scar formation by careful matological surgery. The final scar is less no- epidermal alignment. ticeable in older patients with skin laxity Avoids a depressed scar by precise and in lighter-skinned patients. This method eversion of skin edges. is appropriate in conjunction with other re- Secondary intention constructive techniques. Secondary intention Spontaneous healing—wound left “open” to method (spontaneous healing) is ancient and heal. well established. It can be used in lieu of Closure by secondary intention is an adequate alternative to other complicated reconstruction for certain surgi- wound-closure techniques (e.g., head and cal defects. This method also depends on the neck). three stages of wound healing to achieve the Spares patient more complex procedures ultimate result. (e.g., flap, skin grafts). Delayed primary closure. Delayed pri- Useful in superficial or deep defects mary closure is a combination of the other resulting from dermatological surgery. two types of wound healing. It is often in- Appropriate in conjunction with other tentionally applied to lacerations that are not reconstructive techniques. considered clean enough for primary closure Delayed primary closure and are at high risk of infection, such as heav- Combination of the other two types of ily contaminated wounds, wounds from an- wound healing. Intentionally applied to lacerations not imal or human bites, and wounds with de- considered clean enough for primary layed presentation. Management of wounds closure Wounds that are at high risk of requiring delayed primary closure includes infection (e.g., bites, wounds with delayed cleansing the wound (refer to wound cleans- presentation). ing); debridement; saline-soaked packing, if needed; and dressing the wound. Consider immobilizing extremity wounds. APNs should reassess wounds and close in 3–5 days, if in- dicated. Some wounds may need to heal on If dead space is limited with opposed their own via secondary intention (granula- wound edges, then new tissue has limited tion without mechanical closure) (Lloyd, Mar- room for growth. Atraumatic handling of tis- que, & Kacprowicz, 2007; Roberts, 2010). sues contribute to a better result. Avoidance Prophylactic antibiotics are occasionally pre- of tight closures and undue tension also con- scribed, but their use is neither mandatory tribute to a better result. nor of proven benefit (Roberts, 2010). Secondary intention. Secondary healing occurs when a wound is left open to heal by granulation, contraction, and epithelializa- Factors Affecting Wound Healing tion. Closure by secondary intention is an adequate alternative to other wound-closure Preexisting factors that may predispose pa- techniques, especially on concave areas of tients to wound infection or poor wound heal- the head and neck. The results achieved are ing include chronic conditions (e.g., diabetes, aesthetic and functional and can spare the chronic renal disease), advanced age, steroidCopyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
    • October–December 2010 r Vol. 32, No. 4 Wound Care and Laceration Repair 363 Table 3. Factors affecting wound healing D = Diabetes: The long-term effects of diabetes impair wound healing by diminishing sensation and arterial inflow. In addition, even acute loss of diabetic control can affect wound healing by causing diminished cardiac output, poor peripheral perfusion, and impaired polymorphonuclear leukocyte phagocytosis. I = Infection: Infection potentiates collagen lysis. Bacterial contamination is a necessary condition but is not sufficient for wound infection. A susceptible host and wound environment are also required. Foreign bodies (including sutures) potentiate wound infection. D = Drugs: Steroids and antimetabolites impede proliferation of fibroblasts and collagen synthesis. N = Nutritional problems: Protein-calorie malnutrition and deficiencies of vitamins A, C, and zinc impair normal wound-healing mechanisms. T = Tissue necrosis: Resulting from local or systemic ischemia or radiation injury, impairs wound healing. Wounds in characteristically well-perfused areas, such the face and neck, may heal surprisingly well despite unfavorable circumstances. Conversely, even a minor wound involving the foot, which has a borderline blood supply, may mark the onset of a long-term, nonhealing ulcer. Hypoxia and excessive tension on the wound edges also interfere with wound healing because of local oxygen deficits. See, for example, the pressure ulcers shown in the image below. H = Hypoxia: Inadequate tissue oxygenation due to local vasoconstriction resulting from sympathetic overactivity may occur because of blood volume deficit, unrelieved pain, or hypothermia, especially involving the distal extent of the extremities. E = Excessive tension on wound edges: This leads to local tissue ischemia and necrosis. A = Another wound: Competition between several healing areas for the substrates required for wound healing impairs wound healing at all sites. L = Low temperature: The relatively low tissue temperature in the distal aspects of the upper and lower extremities (a reduction of 1◦ C–1.5◦ C [2◦ F –3◦ F] from normal core body temperature) is responsible for slower healing of wounds at these sites. Image reprinted with permission from eMedicine.com, 2010. Retrieved from http://emedicine.medscape.com/article/194018-overview use, chemotherapy and other immunosup- H = Hypoxia pressant agents, nutritional factors (e.g., mal- E = Excessive tension on wound edges nutrition, decreased vitamin C, decreased protein intake), obesity, and connective tis- A = Another wound sue disorders (e.g., scleroderma, Marfans dis- L = Low temperature (Stillman, 2010) ease) (Singer & Hollander, 2003). To recall the factors that adversely affect wound healing, one can use the mnemonic “DIDN’T HEAL” Systematic Wound Management (Table 3): All wounds have the potential for contamina- D = Diabetes tion. It is assumed that the longer a wound I = Infection is open, the more skin bacteria migrate into wound. Infection generally requires 105 or- D = Drugs ganisms per gram of tissue (most wounds N = Nutritional have <103 organisms/g of tissue). Approxi- mately 5% of wounds seen in the emergency T = Tissue necrosis department (ED) become infected (Lammers,Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
    • 364 Advanced Emergency Nursing Journal Hudson, & Seaman, 2003). However, some ar- the level of wound contamination, and any eas are at low risk of infection such as the materials involved in the injury (e.g., wood head and neck (1%–2%) and extremities (4%– splinters, shattered glass, shredded metal). 7%) (Singer & Hollander, 2003). Any injuries involving the hands should also It was previously thought that wounds include the hand dominance, patient occupa- closed greater than 6–8 hr after injury had tion, and any previous hand injuries. In ad- higher rates of infection. In general, the dition, for injuries involving hands, it is im- likelihood of wound infection increases with portant to determine the circumstances of time to definitive wound care. A delay in injury and position of part at the time of wound cleaning is the most important fac- injury. A tendon injury of the hand may tor and may allow bacteria contaminating the be missed if the wound is not explored in wound to proliferate. A delay of only a few the position of injury. History should also hours in treatment of a heavily contaminated include tetanus-immunization status, aller- wound can result in infection. The site of the gies (particularly to local anesthetics, antibi- wound, amount of tissue damage, and degree otics, and latex), preexisting medical condi- of contamination are additional factors that tions/comorbidities (e.g., cancer, connective may influence whether or not the wound will tissue diseases, diabetes, hepatitis, human im- be closed or will remain open. If there is sub- munodeficiency virus infection, renal failure), stantial risk that the closure of a particular and medications such as steroids that may in- wound might result in infection, the wound fluence rates of infection and wound healing. should be cleansed, debrided, and left open. The history of present illness should also in- Upon reassessment in 3–5 days, the wound clude the onset, location, duration, and char- can then be sutured if there is no indication of acteristics (e.g., quality, severity, and radiation infection. This is known as delayed closure. In of pain) related to the injury. What aggravates a classic article by Edlich, Thacker, Buchanan, it? What relieves it? These are questions to ask & Rodeheaver (1979), the authors noted that the patient. The patient should also be ques- “the fundamental basis for delayed primary tioned about the presence of a foreign body closure is that the healing open wound grad- sensation, swelling, warmth, redness, pus, or ually gains sufficient resistance to infection to wound drainage and any neurologic symp- permit an uncomplicated closure” (p. 169). toms, including motor or sensory deficits When a wound is left “open”to heal by granu- (Bass & Levis, 2010). Finally, it is impera- lation, contraction, and epithelialization, it is tive and important to ask the patient if any known as secondary intention. medications were taken or treatments were rendered (e.g., cleansing of the wound, ele- vation of the limb, pressure-dressing applica- PATIENT ASSESSMENT tion, splinting, removal of foreign body, use of After the patient provides the chief com- over-the-counter medications) before arrival plaint, a thorough history and physical exami- in an emergency care setting. nation must be performed. Even patients with single-system injuries, such as lacerations, re- Physical Examination quire comprehensive evaluation. All wounds should be examined for amount of tissue destruction, degree of contamina- History tion, presence of foreign bodies (FB), and in- One of the most fundamental aspects of jury to underlying structures. Before wound wound management begins with a careful ex- examination, maximize lighting and ensure amination of history. The history should in- that patient is in a supine position (faint- clude the time and mechanism of the injury, ing is a common occurrence during woundCopyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
    • October–December 2010 r Vol. 32, No. 4 Wound Care and Laceration Repair 365 examination, preparation, and repair). To Wounds should be explored in the position achieve adequate visualization, a hemostatic of injury. For example, extensor tendons in field of the wound may need to be established the hand are superficial and covered only by by using either direct pressure or a properly skin and a thin layer of fascia and are highly placed tourniquet proximal to the wound. susceptible to injury. Flexor tendon injuries Providing local anesthetic (i.e., digital block) are more difficult to diagnose and more chal- before wound inspection and irrigation is es- lenging to treat than extensor tendon injuries. sential for patient comfort and in obtaining a In general, ED repair of flexor tendons is not more comprehensive examination. However, performed by APNs but is referred. distal perfusion and motor and sensory func- Nerve injuries can also occur because these tion of the affected area must be assessed be- are adjacent structures. Therefore, it is impor- fore the use of anesthetics. tant to examine the patient for underlying- Physical examination of the affected area structure injuries in a bloodless field, inspect- should adequately assess for nerve, tendon, ing and palpating the wound with adequate vessel, and joint involvement. The vascular as- exposure. The patient should also be exam- sessment should include color, capillary refill, ined under range of motion, before and after and palpation of distal pulses. A neurologic anesthesia, motor strength and stability, sen- examination should include testing of the sur- sation, and distal circulation. rounding and distally distributed nerves and assessing two-point discrimination. Evaluate Foreign Bodies musculoskeletal function, concentrating on potentially involved muscles, tendons, and Foreign bodies require identification and re- joints. A functional assessment of movement moval. There are various methods of identi- helps to refine the potential musculoskeletal fication and several decisions that must be damage that may have occurred during injury made regarding the decision to remove a for- and foreign body deposition (Roberts, 2010). eign body in an emergency care setting. Assess and document wound characteristics, including location, size, color, level of con- Identification tamination, signs of inflammation (edema, The identification of retained FB is an im- erythema), and presence and type of visible portant component in wound evaluation. Re- FB. tained FB can lead to complications and fail- ure to diagnose a retained foreign body is the SPECIAL CIRCUMSTANCES second leading cause of malpractice in the ED related to wound care (along with missed Underlying Structures fractures and tendon injuries) (Blankenship If injury to the underlying structures, such & Baker, 2007; Shepherd, McGahan, & Lee, as bones and/or joints, tendons, vessels, and 2007). It is important for ANPs to take mea- nerve are found, the nurse practitioner may sures to insure that FB are not missed during choose to forego wound closure and consult wound care. Every wound should be explored with surgical specialist. In general, orthope- for FB; however, the practitioner should not dic injuries will require rest, ice, elevation, tell the patient that a foreign body is not and splinting; vessel injuries should be iden- present in the wound. Instead, state that to tified and referred (do not clamp or tie). It the best of your ability with x-ray film and ex- is important to assess for tendon lacerations ploration, you are not able to detect a foreign during wound examination and exploration. body. Tendon lacerations may be caused by closed Digital radiographs are preferred over fist injury with even seemingly superficial plain films for identification of FB. Digital lacerations. radiographs allow adjustments to maximizeCopyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
    • 366 Advanced Emergency Nursing Journal effectiveness. Plain films should be under- of the injury (Blankenship & Baker, 2007, penetrated soft tissue vies in multiple plains 2010). (Blankenship & Baker, 2007; Shepherd et al., 2007). It was previously believed that only PATIENT PREPARATION leaded glass was visible on radiographs; how- ever glass (even pieces <0.5 mm) are visible, Wound Cleansing regardless of depth or composition. Wood has Thorough cleansing of bacteria, soil, and a reported detection rate of only 15% visibility other contaminants from a wound should be on x-ray films. Dried wood in a new wound is accomplished as soon as possible. Cleansing easier to see but degrades with time. Almost of open wounds is painful; therefore, local, all metals are radiopaque and easily identified topical, or regional anesthesia should precede on plain films (Shepherd et al., 2007). the examination and cleaning of a wound. For Other imaging modalities can also be used many years, antiseptic solutions have been to rule out or establish the presence of a FB. used for their antimicrobial properties in and Multiple studies have shown that ultrasonog- around wounds; however, there is a delicate raphy is effective in detecting FB such as veg- balance between killing bacteria and injuring etative matter, wood, and plastic that are not tissue. Intact skin can withstand strong mi- visible on x-ray films. It has shown to have a crobicidal agents, whereas leukocytes and the sensitivity as high as 87% for retained wood FB exposed cells of skin and soft tissue can be at least 2.5 mm in length Computed tomogra- damaged by these agents. As a general rule, phy has been successful in identifying thorns, commercially available antiseptics should be spines, wood, fish, and plastic. Magnetic reso- used only to clean intact skin without expos- nance imaging is effective at locating wooden ing wound surfaces to these agents (Durani & FB; however, it is the least available imaging Leaper, 2008). in the ED and most costly study (Blankenship & Baker, 2007, Shepherd et al., 2007. Ultra- Wound Irrigation sonography is considered the gold standard for imaging FB in soft tissue. Most open wounds can be irrigated with co- pious amounts of saline, tap water, or a di- Removal decisions lute (1%) povidone–iodine solution (Moscati, The composition and location of an FB, as Mayrose, Reardon, Janicke, & Jehle, 2007; well as the patient’s medical status, occupa- Roberts, 2010). Properly performed irrigation tion, and recreational activities, greatly affect is effective in removing particulate matter and decision making related to FB removal. The bacteria from the edges of the wound and history, physical examination, and localiza- trapped within. The effectiveness of irrigation tion techniques available will determine the is determined primarily by the hydraulic pres- best time and place for FB removal. Reac- sure at which the irrigation fluid is delivered. tive material, such as wood, should be re- There are multiple commercially available de- moved immediately when accessible, because vises to provide pressure with irrigation. Irri- retained wood will invariably lead to inflam- gation should continue until all visible, loose mation and infection (Graham, 2002). Other particulate matter has been removed. A po- inert materials, such as glass or plastic, may tential complication of wound irrigation is often be removed on an elective basis. With that infectious material can be splashed into deeply embedded inert materials, the time, ef- the face of the clinician, even when the tip of fort, and trauma involved with removal should the irrigation device is held below the wound be weighed against the possible adverse ef- surface. A splash guard, which is plastic cup fects of the foreign material remaining in device that fits on the end of a syringe, can be place (Shepherd et al., 2007). Consider spe- used to contain the splatter and provide the cialty consultation depending on the nature recommended pressure (Figure 1).Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
    • October–December 2010 r Vol. 32, No. 4 Wound Care and Laceration Repair 367 should precede the cleansing, exploration, and closure of a wound. The pharmacology and methods of local anesthetics used in the ED will be discussed. How local anesthetic agents produce nerve- conduction blockage depends on the form of the agent and specific physiologic and cellu- lar activities. The prevention of sodium influx across the nerve membrane forms the phys- iologic basis for conduction blockade. Local anesthetics slow down sodium influx, de- Figure 1. Zerowet attached to a syringe. Use creasing the rate of rise and amplitude of de- of a splash guard (ZeroWet) in the irrigation of a wound. Used with permission from ZeroWet polarization. If sufficient anesthetic is present Splashield, Zerowet, Inc., Palos Verdes, Peninsula, and the firing threshold is not reached, the CA. action potential is not formed. With no ac- tion potential, no impulse is transmitted and Wound Scrubbing impulse conduction is blocked, resulting in Mechanical scrubbing should be reserved local anesthesia (Roberts, 2010). The onset for wounds contaminated with significant and duration of action of anesthetics are in- amounts of bacteria or foreign material in fluenced by a multitude of factors, including which irrigation alone is ineffective in remov- technique of injection, concentration of so- ing visible contaminants from a wound. A 1% lution, nerve fiber diameter, total dose, addi- povidone–iodine solution (Betadine prepara- tion of epinephrine, and pH manipulations. In tion, not Betadine scrub) or pluronic polyols addition, physiochemical determinants such scrub can be used, followed by irrigation with as lipid solubility and protein binding can af- a normal saline solution. Only pluronic poly- fect onset and duration of action. Of the fac- ols or saline should be used near the eyes. The tors, protein binding is the primary determi- use of hydrogen peroxide on open wounds is nant of duration of action. Agents that bind discouraged. more tightly to the protein receptor remain longer in the sodium channel. The greater the Debridement and/or Minor Trimming of Edges protein binding, the greater the duration of Before Closure action. Marcaine is 95% protein bond, carbo- caine is 78% protein bond, and lidocaine is Selective debridement of foreign material and 64% protein bond. devitalized tissue is important. Debridement Duration is also significantly affected by also creates sharp wound edges that are eas- vasoactivity of the anesthetic (lidocaine pro- ier to repair and results in a more cosmeti- duces the most vasodilatation) and the cally acceptable scar. Debridement can be ac- blood supply of the region anesthetized. complished with a scalpel or tissue scissors Epinephrine causes vasoconstriction and de- and small tissue forceps. The jagged wounds creases systemic absorption, thus allowing edges are stabilized with skin forceps and the more drug to reach the nerve. The addition scalpel, or scissors are used to cut away devi- of epinephrine increases the duration of ac- talized tissue. After debridement, the wound tion and the amount of drug that can be should be irrigated again to remove any re- used. It extends action ranges from 1.3 to 10 maining tissue debris (Roberts, 2010). times longer than lidocaine alone. The use of epinephrine decreases the amount of bleed- LOCAL ANESTHETIC AGENTS ing. Do not use epinephrine in fingers, toes, Wound management maybe painful; there- tip of the nose, pinna of the ear, or penis. fore, local, topical, or digital anesthesia Complications that can be seen with the useCopyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
    • 368 Advanced Emergency Nursing Journal of anesthetics with epinephrine are ischemia, epinephrine should not exceed 4.5 mg/kg, palpitations, and tremors. and the maximum total dose should not exceed 300 mg. Once the maximum dose of lidocaine is given, it should not be repeated Types of Anesthetic Agents for 2 hr. There are several types of anesthetic agents Mepivacaine. Mepivacaine (Carbocaine) used in the care of patients with lacerations. is also a widely used anesthetic in the emer- These agents include, but are not limited to, gency setting. The onset of action is immedi- topical and injected agents. ate for local and slightly slower onset of ac- Topical. Topical anesthesia is great for un- tion, that is, 6–10 min for simple blocks. The complicated lacerations and most effective duration of action for local is 30–60 min and for pediatrics, face, and scalp And is lim- 90–180 min for blocks. Mepivacaine (carbo- ited to 5 cm or smaller. Topical anesthet- caine) has less vasodilatory effect than lido- ics should not be used in areas where there caine. The maximum dose is 5 mg/kg (Marx, is a single blood supply (e.g., fingers, toes, Hockberger, & Walls, 2006). The concentra- nose, pinna of ear, or penis) or mucus mem- tion comes in 1% and 2%. branes. Topical anesthetics come in liquids Bupivacaine. Bupivacaines (Marcaine, or gels. Topical anesthetics include lidocaine– Sensorcaine) are amides and widely used in epinephrine–tetracaine (LET) and topical– emergency settings. It has a slow onset of lidocaine–epinephrine. The technique for action, slower for local, and 8–12 min for sim- topical anesthesia is to use a 2×2 sponge or ple blocks. The duration of action is 30–60 cotton ball saturated and applied to wound min for locals and 240–480 min for blocks. for 15-20 min. A zone of blanching around The maximum dose is 1.5 mg/kg without the wound indicates anesthesia. Five percent epinephrine and 3 mg/kg of 0.25% solution. of wounds anesthetized with a topical anes- (Marx et al., 2006). The concentration is thetic will require supplemental infiltration available in 0.25% and 0.5%. (Hirschmann, 2008). EMLA cream is rarely used to anesthetize wounds since it takes Anesthetic for Patients With Allergies about an hour for anesthesia to occur. Alternative for patients with allergies include Infiltration. Three anesthetic solutions the use of preservative free. The older anes- commonly used for local infiltration and sim- thetics ester vs. amide had a higher rate of al- ple nerve blocks include lidocaine, mepiva- lergies. For some patients, the use of Diphen- caine (Carbocaine), bupivacaine (Marcaine hydramine (benadryl) is an option for local and Sensorcaine ). anesthesia. 50-mg (1-ml) vial is diluted in a sy- Lidocaine. Lidocaine (Xylocaine) is the ringe with 4 ml of normal saline to produce most commonly used, rapid onset anesthetic a 1% solution. Diphenhydramine (benadryl) is agent. Onset is almost immediately in local more painful than anesthetic, and the pain not infiltrate, and for blocks, the anesthesia is reduced by buffering. It produces anesthesia about 4–10 min. Lidocaine has good tissue- for 30 min. spreading properties and readily penetrates nerve sheaths. The duration of action for Toxicity of Local Anesthetics nerve blocks is 75 min (range, 60–120) and for local infiltrates is 20–30 min. In normal, Toxicity of local anesthetics may include healthy adults, the maximum recommended three reactions: cardiovascular reactions, ex- dose of lidocaine injection with epinephrine citatory central nervous system effects, and for local anesthesia should not exceed vasovagal syncope secondary to pain and anx- 7 mg/kg, and the maximum total dose should iety. Cardiovascular reactions may include hy- not exceed 500 mg. The maximum recom- potension and bradycardia caused by a my- mended dose of lidocaine injection without ocardial inhibitory effect of the anesthetic.Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
    • October–December 2010 r Vol. 32, No. 4 Wound Care and Laceration Repair 369 Local anesthetics’ solutions can cause ex- pain. Buffering lidocaine with bicarbonate (1 citatory phenomena in the central nervous ml of standard bicarbonate solution to each system, which can cause seizures. Both car- 10 ml of anesthetic) significantly reduces the diovascular and nervous system effects are pain of injection. Local anesthetic solutions caused by an inadvertent injection of a vessel, have acidic pH for stability. These solutions causing a bolus to heart or brain. make physiological sense to use to buffer the anesthetic since the body has to undergo a Methods to Decrease Pain pH change for anesthesia to work. In addition, Choice of needles. Once an anesthetic has adding bicarbonate reduces the time for the been chosen, consider methods to decrease onset of anesthesia and increases the inten- pain during local injection. The pain of injec- sity of the blockade. However, it does reduce tion is reduced by using a small-gauge needle. the shelf life of the anesthetic. Warming the Ideally, a 30-gauge needle is used if injections anesthetic has shown improvement in reduc- are made through the skin, and a 25- to 27- ing the pain of injection. gauge needle is used if injections are made thought the cut edges. ANESTHESIA TECHNIQUES Rate of injection. Because the expansion of soft tissue stimulates pain receptors in skin, There are several anesthetic techniques. Anes- injecting anesthetic slowly (≈10 s) causes less thesia techniques include direct wound infil- pain than rapid injection. Not only do smaller tration, parallel margin infiltration, and digital needles hurt less than larger needles while blocks. piercing the skin, a small needle slows down the rate of injection and reduces the rate of Direct Wound Infiltration tissue distention. Direct wound infiltration works on most mi- nor wounds. It requires multiple adjacent de- Methods of Injection positions of anesthetic along the length of the wound on either side. This technique is re- Injecting into deep tissues is less painful than ported as less painful because the skin is not injecting into superficial tissues; injecting into pierced. Injection is performed immediately wound edges (rather than into the tissue sur- beneath the dermis at the junction of the su- rounding a wound) hurts less and does not perficial fascia using a small 25-, 27- or 30- usually increase risk of infection. A digital gauge needle. blocks is less painful than injecting directly into the digits. Digital distraction technique by lightly rubbing or scratching the skin prox- Parallel Margin Infiltration (Field Block) imal to the wound “distracts” the pain re- A parallel margin infiltration or field block re- ceptors and decreases pain. Commercial dis- quires fewer needle sticks and is the choice tracter products such as Buzzy (MMJ Labs for dirty wounds. The technique uses a LLC, Atlanta, GA) are great for pediatrics. 1 1/4 – 2-inch needle to lay down adjacent Buzzy uses natural pain relief by using vibra- tracks of anesthesia parallel to the wound tion to distract attention away from the site, edge. thereby dulling or eliminating sharp pain. Digital Blocks Buffering Solutions The most common nerve block used in the Increasing the pH of an anesthetic by adding ED for wound care is the digital block. It is sodium bicarbonate can dramatically de- the recommended anesthetic for lacerations creases a patient’s pain. Lowering the pH of an distal to the level of the midproximal phalanx anesthetic by adding epinephrine increases of the finger or toe (Trott, 2005). It is also theCopyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
    • 370 Advanced Emergency Nursing Journal preferred anesthetic for nail removal, nail-bed trigger finger, anesthesia of the entire digit repair, paronychia, and removal of FB. rapidly ensued. Chiu was so impressed with Each finger are comprised of four digital the ease and rapid onset of anesthesia that nerves or toe, including the great toe and he conducted further studies. In 1990, Chiu thumb. The palmer digital nerves have the injected 10% methylene blue into the flexor most extensive sensory distribution and are tendon sheath of 10 cadaver fingers. The re- responsible for both distal finger and fingertip sults showed a completed staining of the en- sensation, including the nail bed. The dorsal tire flexor tendon sheath and centrifugal dif- nerves have a lesser distribution but do have fusion of the blue dye along the entire circum- overlap with the palmer nerves. Thus, all four ference of the proximal phalanx, including all branches must be blocked for complete anes- four digital nerves. thesia (Trott, 2005). The transthecal digital block has several ad- vantages over the traditional ring block, in- cluding single injection versus multiple injec- Conventional Ring Block tions, smaller volume of anesthetic used, and The ring block is the most commonly per- avoidance of risk to digital neurovascular bun- formed digital block in the ED. It requires dles, including spasm and direct trauma. The two needle sticks and four small injections onset of anesthesia is rapid, with anesthesia of anesthetic. A 3-ml syringe with a small- occurring within 3–5 min. A potential dis- gauge needle (25–30 gauges) is used. The rec- advantage is that the transthecal method re- ommend anesthetic is 1% lidocaine without quires violation of the flexor synovial sheath epinephrine or mepivacaine. The APN should and potential risk of tendon trauma or in- prepare the skin first with iodine and then fection. It is vital to use a small needle (25 with alcohol. With the hand pronated, the gauge or higher) and to sterile technique to needle is introduced into the dorsal–lateral minimize the risk (Flarity, 2002; Chiu, 1990). aspect of the proximal phalanx in the web The authors are unaware of any published space just distal to the metacarpal–phalangeal reports of complications in the literature to joint (to anesthetize the dorsal nerve). Ad- date. vance the needle until it touches bone, and The effectiveness of the transthecal block deposit 0.5 ml of the anesthetic. Without is 91%–99%. Rarely is an additional injection reinserting the needed, slightly withdraw and of local anesthetic or a repeat block required then advance toward the volar surface and in- when a transthecal block is performed. In ject 1 ml of the anesthetic. Repeat the pro- one author’s experience with more than 200 cedure on the other side of the digit to com- cases, she has needed to supplement the anes- plete the block. A complete block is usually thetic in only three cases, one for a thumb achieved within 4–5 min. If there is difficulty and two for the great toe. Of the four failed achieving a good block, it may be repeated cases reported by Chiu, three occurred in the with half the dose and angled more toward thumb. Low et al. (1997) felt that the size of the underside of the bone (Trott, 2005). the digit was the cause of the failure and sug- gested that a larger volume of solution may be needed to anesthetize the thumb. Transthecal Digital Block and Modified A traditional transthecal block is performed Transthecal Block using the flexor tendon of the palmer surface The transthecal digital block is an effective just proximal to the metacarpophalaneal join. alternative method to the ring block. Chiu The authors use a modified transthecal block (1990) first described the transthecal digital that uses the metacarpal crease on the paler block. Chiu observed that following an injec- surface as the anatomical landmark (Table 4). tion of steroid and lidocaine (Lignocaine) into The modified transthecal block is easier and the flexor tendon sheath as a treatment for offers the same advantages.Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
    • October–December 2010 r Vol. 32, No. 4 Wound Care and Laceration Repair 371 Table 4. Modified transthecal block procedure The procedure Equipment With the patient’s hand supinated, locate the midpoint of the 3-ml syringe metacarpal crease on the palmer surface (Figure 2) 1 /2 -Inch 27- or 30-gauge needle Cleanse the skin with iodine or cholorahexidine, followed 12 ml of 0.5% Sensorcaine by alcohol Iodine or cholorahexidine Apply pressure with your nondominant thumb proximal to the Alcohol pads injection site (directs the flow of the anesthetic distally) Gloves Hold for 30s after injection (Figure 3) Insert the needle perpendicular to the skin until you hit bone. Withdraw the syringe slightly, and inject the medication. Modified Transthecal block, adapted from “Methods of Digital Blocks” by K. Flarity- Reed, 2002, Journal of Emergency Nursing, 28(4), pp. 351–354. The following equipment is needed: mod- Hold for 30 s after injection (Figure 3). In- ified transthecal block, 3-ml syringe, 1/2 -inch sert the needle perpendicular to the skin un- 27- or 30-gauge needle, 12 ml of 0.5% sensor- til the bone is felt. Then, withdraw the syringe caine, iodine, alcohol pads, and gloves. slightly and inject the medication. Initially, pa- tients may report that the finger feels fat or Modified transthecal block procedure swollen. Within 1 min after injection, the pa- With the patient’s hand supinated, locate the tient will feel a warm sensation in the injected midpoint of the metacarpal crease on the digit and anesthesia within 3–5 min. palmer surface (Figure 2). Cleanse the skin with iodine or chlorhexidine, followed by al- SUMMARY cohol. Apply pressure with your nondomi- nant thumb proximal to the injection site; Wound management is a common proce- this directs the flow of the anesthetic distally. dure performed by advanced practice nurses Figure 2. Anatomic landmark for modified trans- Figure 3. Pressure application for modified trans- thecal block. The anatomic landmark for modified thecal block. Apply pressure with your nondomi- transthecal block is the midpoint of the metacarpal nant thumb proximal to the injection site for mod- crease of the palmar surface. ified transthecal block.Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
    • 372 Advanced Emergency Nursing Journal working in emergency care settings. The ulti- Hirschmann, J. V. (2008). Topical and oral antibiotics in mate goal of wound care is to promote proper wound care. Cutis, 82(2, Suppl. 2), 18–20. wound healing to restore function and maxi- Lammers, R. L., Hudson, D. L., & Seaman, J. E. (2003). Pre- diction of traumatic wound infection with a neural mize restoration of cosmetic appearance (Mc- network-derived decision model. American Journal Caig & Nawar, 2006). This article outlined the of Emergency Medicine, 21, 1–7. phases of wound healing, discussed factors Lloyd. J. D., Marque, M. J., & Kacprowicz, R. F. (2007). that may increase the risk for infection of non- Closure techniques. Emergency Medical Clinics of surgical wounds and use of anesthetics. The North America, 25, 73. Low, C. K., Vartany, A., & Diao, E. (1997). Comparison of various types of wound closures will be dis- transthecal and subcutaneous single-injection digital cussed in Part II. blocks techniques in cadaver hands. Journal of Hand Surgery, 22, 897–900. Marx, J. A., Hockberger, R. S., & Walls, R. M. (2006). REFERENCES Rosen’s emergency medicine: Concepts and clinical Bass, A. M., & Levis, J. T. (2010). Foreign body re- practice (6th ed.). St. Louis, MO: Mosby. moval, wound. Retrieved June 22, 2010, from McCaig, L. F., & Nawar, E. W. (2006). National hospital http://emedicine.medscape.com/article/1508207- ambulatory medical care survey: 2004 emergency de- overview partment summary. Advance Data, 372, 1–29. Blankenship, R. B., & Baker, T. (2007). Imaging modalities Moscati, R. M., Mayrose, J., Reardon, R. F., Janicke, D. M., in wounds and superficial skin infections. Emergency & Jehle, D. V. (2007). A multicenter comparison of Medical Clinics of North America, 25, 223–234. tap water versus sterile saline for wound irrigation. Chiu, D. T. (1990). Transthecal digital block: Flexor ten- Academic Emergency Medicine, 14, 404–409. don sheath used for anesthetic infusion. Journal of Roberts, J. R., Hedges, J. R. (2009). Clinical procedures Hand Surgery, 15(3), 471–477. in emergency medicine. 5th ed. Philadephia, PA: Durani, P., & Leaper, D. (2008). Povidone-iodine: Use in Elsevier. hand disinfection, skin preparation, and antiseptic ir- Roberts, (2010) Physical examination. Foreign body rigation. International Wound Journal, 5, 376–387. removal, wound. Retrieved July 20, 2010, from Edlich, R. F., Thacker, J. G., Buchanan, L., & Rodeheaver, http://emedicine.medscape.com/article/1508207- G. T. (1979). Modern concepts of treatment of trau- overview matic wounds. Advances in Surgery, 13, 169–197. Shepherd, M., McGahan, M. C., & Lee, J. (2007). Diag- Emergency Nurses Association (2008). Competen- nostic modalities for the detection of soft tissue for- cies for nurse practitioners in emergency care. eign bodies. Advanced Emergency Nursing Journal, Retrieved June 29, 2010, from http://www.ena. 29(4), 297–308. org/IQSIP/NursingPractice/advanced/Documents/ Stillman, R. (2010). Wound care. Retrieved July 1, ENANPCompetency.pdf 2010, from http://emedicine.medscape.com/article/ Flarity-Reed, K. (2002). Methods of digital blocks. Jour- 194018-overview nal of Emergency Nursing, 28(4), 351–354. Singer, A., & Hollander, J. (2003). Lacerations and acute Graham, D. D., Jr. (2002). Ultrasound in the emergency wounds: An evidence based guide. Philadelphia, PA: department: Detection of wooden foreign bodies in F.A. Davis Company the soft tissues. Journal of Emergency Medicine, 22, Trott, A. T. (2005). Wounds and lacerations: Emergency 75–79. care and closure (3rd ed.). Philadelphia, PA; Mosby. For more than 82 additional continuing education articles related to Advanced Nursing Practice topics, go to NursingCenter.com/CE.Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.