Current Management of Acute Cutaneous Wounds

Current Management of Acute Cutaneous Wounds
N Engl J Med 2008;359:1037-46.

Primary Goal of Wounds Management
No infection
Normal function
Excellent cosmetic result

General Principles of Care
All wounds should be thoroughly cleansed with tap wateror normal saline.
For heavily contaminated wounds, high-pressureirrigation (>7 psi) can be achieved with the use of a 10-to-50-mlsyringe and splatter shield.
A moist environment for the wound accelerates healing, thus improving cosmesis and reducing pain, therisk of infection, and the costs of care.

Abrasions
Post-Traumatic Tattooing
This condition is most commonly seenwith injuries from explosions or fireworks and "road rash" (abrasionof the skin from contact with a surface containing asphalt,tar, or dirt, with embedding of these particles).
Initial treatmentconsists of the meticulous removal of all particles with standardsurgical scrub-brushes.
During this procedure, topical lidocaine,local infiltrative anesthetics, or regional anesthetics shouldbe used.

Lacerations
Skin Tears
Plantar Puncture Wounds
Mammalian Bites
Subungual Hematomas

Skin Tears
Long-term corticosteroid therapy, the elderly.
Category I tears (without tissueloss), the wound edges can be approximated with surgical tapes,and the area covered with a non-adherent dressing.
Category II skin tears (partial tissueloss) and category III skin tears (complete tissue loss) canbe managed with absorbent dressings suchas petroleum-based gauzes, hydrogels, foams, hydrocolloids,nylon-impregnated gauzes, and silicone-coated dressings.

Treatment of a Category I Skin Tear of the Dorsal Forearm.

Plantar Puncture Wounds
Superficial infection rate (i.e., cellulitis) rangesfrom 2 to 10%.
Most of the infections are causedby Staphylococcus aureus or Streptococcus pyogenes.
Cleansing alone may be adequate therapy and antibiotics shouldbe administered immediately in patients who have signs and symptomsof infection.

If the presence of a foreign body is suspected,CT imaging or ultrasonography should be usedto detect non-adiopaque objects.
The incidenceof osteomyelitis (in most cases caused by pseudomonas), chondritis,and septic arthritis is considerably lower, antibacterialagents (e.g., dicloxacillinand ciprofloxacin) should be used.

Mammalian Bites
The risk of infection after dog, cat, and human bites rangesfrom 3 to 18% for dog bites to 28 to 80% for cat bites.
After high-pressure irrigationof the wound, it is safe to close most bite wounds up to 12 hours after injury (healing by primaryintention).
Puncture wounds and scratches should be allowedto heal by secondary intention.
These wounds should be coveredwith a topical antimicrobial agent and an absorbent dressing.

For large, heavily contaminated lacerations, delayed primaryclosure, after an observation period of 3 to 5 days (healingby tertiary intention.
Human bites thatare sustained over the metacarpophalangeal joints ("clenched-fistbites") are especially prone to infection.
These bites requireaggressive irrigation and treatment with antibiotics (e.g.,amoxicillin–clavulanate) and should not be closed.

Subungual Hematomas
In the past, forhematomas involving > 50% of the nail bed, many physiciansrecommended removal of the nail and repair of any underlyinglaceration of the nail bed, since the incidence of underlyinglacerations was found to be quite high (especially in associationwith underlying tuft fractures).

Simple nail trephination with theuse of a handheld portable cautery is recommended for most subungualhematomas.
Nail removal should probably be reservedfor subungual hematomas that are associated with disruptionof the nail or surrounding nail folds.
Do not routinely replacethe nail plate or put other materials, such as aluminum foilor gauze impregnated with petrolatum, to separate the nail foldfrom the nail bed unless there has been a serious injury thatrequires surgical repair.

Burns
First-degree burns are limited to the epidermis and are erythematousand painful. They generally heal within several days.

Second-degreeburns involve all of the epidermis and part of the underlyingdermis and are classified according to the depth of dermal involvement.

Superficial second-degree (or partial-thickness) burns involvethe upper layers of the dermis and are characterized by clearblisters and weeping.
They are painful and sensitiveto touch and blanch with pressure.
These burns usually healwithin 2 weeks, with minimal scarring.

Deep second-degree burnsinvolve the deeper layers of the dermis are characterizedby hemorrhagic blisters and are covered with a layer of whiteor red injured dermis that does not blanch.
Theseburns usually do not heal for at least 3 weeks and often resultin hypertrophic scarring and contractures, especially in children.

Full-thickness burns may be dark brown or tan and havea leathery texture that is insensitive to touch.

A
B
Determination of Burn Depth
C
A superficial second-degree burn is shown in Panel A, a deep second-degree burn in Panel B, and a third-degree burn in Panel C.

"Rule of Nines”

Escharotomy
Circumferential burns (burns that completely encircle a limb,the neck, or the torso) can compromise perfusion, and it maybe necessary to relieve the pressure by means of an escharotomy.

Cooling of Burns
Cooling of burns with the use of cold (15 to 25°C) tap waterwithin 30 minutes should continue until the pain is substantially reducedor resolves.

Management of Blisters
Intact blisters healedfaster and were less likely to become infected than blistersthat were ruptured.
Removal of the necrotic epidermis slowed reepithelializationand increased the rate of infection and scarring.

Blisterslarger than 3 cm in diameter and those over mobile areas usuallyrupture spontaneously and may be aspirated under sterile conditions.
When blisters rupture, the wound should be washed with soapand water, and the nonadherent necrotic epidermis carefullyremoved.

Local Therapy for Burns
First-degree burns do not require any specific therapy,topical NSAIDs or aloe vera maybe used to reduce the pain.
Superficialsecond-degree burns should be treated with a topical antimicrobialagent or an absorptive occlusive dressing.
Deep second-degree burns andthird-degree burns should be covered with a topical antimicrobialagent, and the patient referred to a burn specialist for consultationregarding the need for excision and grafting.

Traditional topical antimicrobial agents that contain silver,such as silver sulfadiazine, confer wide antimicrobial coverageand are most useful for deep second-degree burns and third-degreeburns.
A large number of synthetic and biologic occlusive dressingshave been evaluated for the local management of burns, these dressings have been shown to result in less pain, betteracceptance and compliance, and more pleasing cosmetic resultsin patients with superficial partial-thickness burns.

Chemical Burns
Initial treatment consistsof copious water lavage commencing at the scene and removalof any particles.
A burn from hydrofluoric acid that involves >5% of TBSA, or >1% of TBSA if the concentration of hydrofluoric acid >50%, requires admission for ECG monitoring and serial measurements of calcium levels, sincelife-threatening arrhythmias and hypocalcemia can occur.

Exposure to hydrofluoricacid leads to intensepain and tissue damage.
Treatment includes copious irrigationfollowed by the application of calcium gluconate gel or subcutaneousinjection of calcium gluconate, with the goal of relieving thepain.

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Current Management of Acute Cutaneous Wounds

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