Assessment

HISTORY

Timing and mechanism of injury are essential 

• Crush injury is more likely to destroy the blood supply
• Contamination of wound by a foreign body increases the likelihood of infection
• Bite wound poses risks of blood-borne diseases and needs to be thoroughly assessed with appropriate cover where necessary.
• Associated injuries in other regions may complicate management protocols.

Associated past medical histories such as diabetes and peripheral vascular disease, anticoagulant use, Immunization history, social history such as smoking and occupational history may predict healing.

-Consider self-harm and safeguarding concerns in the elderly, the pediatric or patient with a mental health history.

EXAMINATION

General body examination. 

Inspection of the wound site.

• Assess depth but avoid the temptation to probe deeper (if it cannot be reliably determined, get more specialist help)
• Prescence of a foreign body.
• Assess the distal neurovascular bundles
• Check for underlying bony injury.

RELEVANT INVESTIGATIONS

X-ray is highly sensitive for detecting radiopaque foreign body.  Ultrasound has high specificity but moderate sensitive for detecting foreign body. However, the sensitivity for radiolucent objects is almost 97%.⁷ CT scan may be required in selected cases.

NEED FOR REFERRAL

A wound to select areas

E.g., Burns, significant face or hand injuries and others.

PROPHYLAXIS

1. Tetanus immunization and prophylaxis following injuries.

A decision regarding tetanus prophylaxis must be made in every patient with an injury.

Immunization status	Immediate Treatment					Later Treatment
	Clean wound	Tetanus prone		High-risk tetanus prone
Those aged 11 years and over have received an adequate priming course of tetanus vaccine with the last dose within 10 years.	None required	None required		None required		Further doses as required to complete the recommended schedule (to ensure future immunity)
Children aged 5-10 years who have received priming course and preschool booster.
Children under 5 years who have received an adequate priming course.
Received adequate priming course of tetanus vaccine but last dose more than 10 years.	None required	Immediate reinforcing dose of vaccine		Immediate reinforcing dose of vaccine	One dose of human tetanus immunoglobulin in a different site
Children aged 5-10 years who have received priming course but no preschool booster.
Includes UK born after 1961 with history of accepting vaccination.
Not Received adequate priming course of tetanus vaccine (includes uncertain immunization status and born before 1961)	Immediate reinforcing dose of vaccine	Immediate reinforcing dose of vaccine	One dose of human tetanus immunoglobulin in a different site	Immediate reinforcing dose of vaccine	One dose of human tetanus immunoglobulin in a different site

Adapted from post exposure management for tetanus prone wounds.^4,5

2. Prophylactic Antibiotic 

Routine antibiotic prophylaxis for simple wounds has no scientific basis. However, following good history taking and proper assessment of individual wounds, 

Prophylactic antibiotics may be prescribed for some select patient group. Examples include;

Risk Factors for wound infection

1. Location: leg and thigh, then arms, then feet, then chest, back, then face then scalp
2. Contamination with devitalized tissue, foreign matter, saliva, stool
3. Blunt (crush) mechanism
4. Presence of subcutaneous sutures
5. Types of repair: risk greater with sutures > staples > steri-strip
6. Anaesthesia with epinephrine
7. High-velocity missile injuries
8. Diabetes.

Adapted from Risk Factors for wound infection.⁹

3. Analgesia/Anesthesia

• Local anesthesia to the injury site serves both functions of allowing for reasonable wound exploration and pain and anxiety control.
• Lidocaine (Xylocaine) is the most common agent used for local and regional anaesthesia. It is safe and fast-acting.
• Dosage: 1 % Lidocaine =10mg/ml 3mg/kg without adrenaline. 7mg/kg with adrenaline. (Used to prolong the anaesthetic effect of Lidocaine but at the risk end artery vasospasm and subsequent tissue ischemia). It should be avoided in end organs such eyes, ears, nose, fingers, toes and the penis.
• Reversal agents for vasospasm induced Lidocaine with adrenaline include; subcutaneous phentolamine or topical nitroglycerine.⁹
• Local anaesthetic toxicity is uncommon but can carry a significant mobidity or mortality.
• Manifestations of local anesthetic toxicity can appear 1 to 5 minutes after the injection, but onset may range from a few seconds to as long as 60 minutes. 

Toxicity manifestations can be categorized as follows:

 – CNS manifestations: Systemic toxicity initiates with symptoms of CNS excitement such as the following: Circumoral and/or tongue numbness, metallic taste, lightheadedness, dizziness, visual and auditory disturbances (difficulty focusing and tinnitus), disorientation, drowsiness, this may be followed by a rapid CNS depression, muscle twitching, seizures and coma.

–  Respiratory depression and arrest.

– Cardiovascular manifestations: Chest pain, Shortness of breath, Palpitations, Diaphoresis, hypotension and syncope.

In lidocaine toxicity management, intravenous lipid emulsion (Intralipid) is the drug of choice.

Learning Bites

Adrenaline prolongs the anaesthetic effect of Lidocaine but at the risk of delay wound healing and lower resistance to infection.

4. Exploration

Wound irrigation and adequate toileting to flush out dirt particles with warm saline (0.9%sodium chloride). It also helps assess anatomical extents of injuries and determine any associated injuries to underlying structures.⁶ Debridement and closure may be done in a well-controlled setting if indicated.

Definitive Treatment:

• Closure

Immediate closure to allow healing by primary intention

Delayed closure followed by healing by delayed primary intention.

Healing by secondary intention.