How to Evaluate Wounds in the Emergency Department

The goals of wound care in the emergency department (ED) are to prevent infection, restore function, and restore physical integrity.

EXAMINATION OF THE WOUND allows the physician to assess the level of care required. Attention to the area of injury, and its underlying structures, guides the physician in deciding whether the wound can be treated in the ED or requires a surgeon.

HISTORY OF PRESENT INJURY

1. Contamination of the wound: Wounds with high concentrations of bacterial contamination (e.g., by feces, saliva, or organic matter) need extensive debridement and irrigation. Some of these wounds may have such extensive contamination that they will require delayed closure.

2. Age of injury: The golden period of wound care is generally considered to be less than 6 to 8 hours following injury. Between 8 and 12 hours, some wounds can be closed without a significant additional risk of infection. It is best to not close wound that is greater than 16 hours unless there is a cosmetic issue. In contrast, in a heavily contaminated wound of the foot, closure may not be safe in as little as 3 hours postinjury.

3. The extent of injury: Inspect all wounds for injuries to deep structures like tendons, nerves, and blood vessels. Pull wounds open and debride so the entire wound can be seen.

4. Past medical history

a) Past medical history: Diabetes, immunosuppression (e.g., caused by steroids, AIDS, cancer treatment), and alcoholism are examples of conditions that affect wound healing. These conditions lead to slower healing and higher infection rates. In the presence of such conditions, sutures should be left in longer and prophylactic antibiotics should be considered.

b) Age of the patient: Patients younger than 2 years and older than 50 years have higher rates of infection.

c) Smoking status: Tobacco use decreases peripheral blood flow and increases the risk of other vascular injuries.

d) Nutritional status: Patients with severe nutritional deprivation have slower wound healing and higher infection rates. Supplemental nutrition may be necessary for these individuals.

e) Medications: Steroids and immunosuppressive medications may slow healing and increase infection rates. Aspirin, antiplatelet agents, and warfarin may cause an accumulation of blood in wounds that are primarily closed, causing swelling and possible infection.

f) Tetanus immunization: Tetanus is a highly preventable and potentially fatal disease. All patients with wounds should be questioned as to their immunization status.

GENERAL INSPECTION

1. Description of wounds: Document length, depth, ability to visualize the base, and shape (stellate, linear, jagged, flap). The entire wound should be visualized. If it is covered by matted blood or hair, gently clean if off.

2. Functionality of wounded area: The initial inspection is used to evaluate functioning of the area as well as distal functioning. Attention to neurologic function (i.e., sensation, reflexes, strength) prior to the use of local anesthesia is important. Muscle movement and tendon function should be evaluated through the entire range of motion. Vascular integrity should be evaluated (i.e., temperature, color, capillary refill, pulses).