Knife Wound Rationale for Procedure

Assess your patient

First, assess your patient. A requirement for you to proceed is that the patient gives consent. In the case of someone who is drunk, there is the problem that they may lack capacity to consent.

Obtain consent

The law which governs consent in this situation is The Mental Capacity Act 2005, and you should have a basic working knowledge of the main points contained in this statute.

There is a temptation to say that you will treat the patient in their ‘best interests’ and whilst this is indeed part of the Act, it comes at the very end of the assessment of capacity. For instance, before getting this far, you should have considered whether the lack of capacity is temporary (it is) and whether you can wait until the patient regains capacity e.g. apply dressings and do a delayed primary suture later.

Lay the patient down

Assuming that the patient can and has given consent, you should plan the procedure. In general all patients undergoing a painful or invasive procedure should be lying down.

The adage ‘the bigger they are the harder they fall’ is particularly true in ED where fit rugby players keel over with monotonous regularity when faced with a needle.

Prepare your trolley

Prepare your trolley as fully as possible. It is ideal to have an assistant with you for any procedure but ED staffing levels often mean you are left on your own to get on with it. In this case, make sure that you can summon help if needed and are not tucked away in an isolated corner of the department.

Prepare the wound

After preparing the patient you should prepare the wound.

Administer the LA

Administer your chosen local anaesthetic with the full knowledge of:

• The dose you are giving
• The maximum level to which you can go

Remember, it is less painful to inject through the side of the wound rather than through the skin itself.

Give enough anaesthetic that it works first time, but without distorting the tissue planes.

WAIT for the anaesthetic to work – it works quickly, but not instantaneously.

Suture the wound

When suturing large areas or multiple wounds, remember that relatively short acting drugs, such as lidocaine, may start to wear off.

Keep the patient lying down

When you have finished, keep the patient lying down for a short period as vasovagal faints are common shortly after a procedure as well as during one.