Learning Objectives: After participating in this activity, the physician should be better able to:
1. Differentiate skin tears by amount of tissue loss and propose an approach for their management.
2. Design an evidence-based plan for antibiotic prophylaxis of commonly encountered wounds in the ED.
3. Categorize burn severity as major, moderate, or minor based on total body surface area (TBSA) and clinical characteristics.
Article from the 2010 Reading List
Current Management of Acute Cutaneous Wounds
Singer AJ, Dagum AB
N Engl J Med
This article is a broad, evidence-based review of wound care management from the Current Concepts series in the New England Journal of Medicine. A wide gamut of wounds is covered in the article including frostbite, lacerations, burns, abrasions, skin tears, and mammalian bites.
The authors begin by reviewing some general principles of wound care including preventing infection, maintaining function, and achieving a good cosmetic result. They suggest routine wounds be cleaned with tap water or normal saline, and contaminated wounds be thoroughly irrigated with a syringe and splatter guard. A moist environment has been shown to prevent cellular dehydration and to stimulate collagen synthesis and angiogenesis. (Am J Surg 1994;167[1A]:2S.) The authors recommend applying an occlusive dressing and a topical antimicrobial ointment for routine wound care. No evidence suggests whether one type of dressing is superior to another, so the authors recommend choosing a dressing based on the clinical situation. Occlusive dressings can be less painful, and may require less frequent changes, but they are also more expensive than a simple gauze dressing with antibiotic ointment.
Superficial abrasions do not extend below the dermis, and are usually managed with a topical antibiotic and dressing. Large, deep abrasions below the dermis may require skin grafting and follow-up with a plastic surgeon. Fireworks, gunpowder, and “road rash” cause tattooing from foreign body particles being imbedded in the skin. Meticulously removing the particles with a scrub brush within 24 hours of the injury under local anesthesia (or procedural sedation in severe cases) may prevent a poor cosmetic result. (J Am Acad Dermatol 1992;26[5 Pt 1]:749.)
The authors recommend using cyanoacrylate skin adhesives for simple lacerations not under tension. They offer various benefits over traditional sutures, including being painless, simple, and quick, and do not require the patient to return to the ED for removal.
Skin tears result from fragile skin, most commonly seen in the elderly and in patients chronically taking corticosteroids. Simple Category I tears do not involve tissue loss, and are managed with surgical tape and nonadherent dressings. Category II and III tears are associated with partial and complete tissue loss respectively, and are managed with absorbent dressings. Simple skin tears presenting within eight hours can be closed with cyanoacrylate adhesive, and all skin tears should be covered with tubular gauze.
Infections from puncture wounds to the foot are most commonly caused by Staphylococcus aureus and Streptococcus pyogenes. Pseudomonas osteomyelitis has been associated with puncture wounds of the foot through a wet tennis shoe, but there are no randomized trials supporting the routine treatment of puncture wounds with prophylactic antibiotics. (J Emerg Med 1995; 13:291.) Antibiotic treatment of puncture wounds remains controversial, but cleaning and removal of foreign bodies is recommended when feasible.
Mammalian bites are associated with a high risk of infection. Cat bites are often deep puncture wounds, and have been associated with an almost 80 percent rate of infection. One study suggests suturing mammalian bites presenting within 12 hours only after copious high-pressure irrigation. (Acad Emerg Med 2000;7:157.) Although it is standard practice to treat all mammalian bites with antibiotics, one meta-analysis suggests that only bites to the hand may benefit from prophylaxis. (Cochrane Database Syst Rev 2001; :CD001738.)
An accurate description of second- and third-degree burns is based on total body surface area (TBSA), age, and depth of injury, and allows the practitioner to classify the burn as minor, moderate, or major. Most burns encountered in the ED are minor, and require minimal therapy. Major burns require treatment in a burn center and multidisciplinary specialty care. First-degree burns such as a bad sunburn are erythmatous, painful, and limited to the dermis. Second-degree burns involve the epidermis and part of the dermis. Second-degree burns are classified as superficial if they involve the upper layer of the dermis, and are associated with blistering and blanch with pressure. Deep second-degree burns involve the lower layer of the dermis, and have more in common with third-degree or full thickness burns because they have a nonblanching, whitish appearance. Full thickness or third-degree burns are insensate, and have a leathery texture.
Major second- and third-degree burns involve more than 20 percent of total body surface area in adults, more than 10 percent TBSA in children, significant burns to eyes, genitalia, or face, and any burn associated with a fracture or significant trauma. Patients with major burns should be managed at a burn center.
Cooling burns with tap water or a wet sheet has been shown to decrease pain. Routine removal or aspiration of blisters should be avoided, but the authors suggest that blisters larger than 3 cm or over areas in which they are likely to rupture spontaneously can be removed.
After reading this article, you should be able to better differentiate skin tears by amount of tissue loss and propose an approach for their management, design an evidence-based plan for antibiotic prophylaxis of commonly encountered wounds in the ED, and categorize burn severity as major, moderate, or minor based on total body surface area (TBSA) and clinical characteristics.
Comment: The first author of this review, Adam Singer, MD, is the emergency medicine expert in wound care with more than 140 publications, many of which are related to wound care in the ED. If you read only one LLSA article this year, I strongly urge it to be this one.
Many controversies remain in wound care, and these are likely to persist because many recommendations come from expert opinion or observational studies at best, rather than hard evidence.
No area of wound management is more controversial than burns. Silver sulfadiazine is commonly prescribed for treating minor burns, but its indiscriminate use has been associated with cellular toxicity, delayed healing, and leucopenia. (Burns 2007;33:139.) Routine use of silver sulfadiazine for first-degree, minor, or partial thickness burns is expensive and messy, and in one study was not superior to honey for preventing infection. (West J Med 2001;175:205.)
Want to start a fistfight at a meeting of burn surgeons? Raise the question of which, if any, blisters require removal. To incite an all-out brawl, ask if the blister should be unroofed, aspirated, or debrided. The authors of this review correctly identify that the controversy stems from an incomplete understanding of the effect of blister formation on the healing process. These authors ultimately advise not popping smaller blisters and removing only ones larger than 3 cm or those likely to rupture on the way home from the ED. If a blister is removed, they recommend more than simple fluid aspiration: Instead use fine iris scissors to remove dead tissue and to clean the base underneath.
The authors also tackle the questions of when to close mammalian bites and which require antibiotic prophylaxis. Most of us are reticent to close a dog bite to an extremity, but these authors cite a study that concluded that it is safe to close most. (Arch Emerg Med 1988;5:156.) Interestingly, the overall infection rate in this study was only seven percent, and none of the patients received prophylactic antibiotics. Most of the infections in this study were bites to the hand that involved sutures. I recommend being careful suturing dog bites of the hand, but be comfortable suturing most other locations. Loosely approximate bite wounds, document well, and instruct patients and family to be vigilant for signs of infection. There is little evidence to support routine antibiotic prophylaxis for mammalian bites, but we all do it, and I do not expect this practice to change.
I was happy to see that the article included a section on frostbite, something rarely encountered here in the Southwest. Frostbite results from freezing the skin, most commonly the extremities. Initial treatment includes opioid analgesics and rewarming in water of about 40°C. Splinting the extremity and treatment with NSAIDs are recommended to decrease vasoconstriction and platelet aggregation. Frostbite injuries are reassessed at 48 hours to determine severity of injury. Frostbite is described similar to burn wounds by depth, appearance, and extent of injury, and like burn wounds, routine removal of blisters is not recommended unless they are larger than 3 cm.
A time-saving technique, which comes from experience at a busy inner city hospital ED, is using tap water irrigation when suturing simple lacerations. Severely contaminated wounds require pressure irrigation and debridement at the bedside, but most wounds can be washed out in the ED sink by patients themselves after adequate analgesia is administered. The authors do not recommend prophylactic antibiotics for most lacerations, abrasions, or burns. They even call into question the utility of antibiotics for deep puncture wounds of the foot, a scenario for which irrigation and a valiant search for a foreign body are the only things likely to make a difference.
CME Participation Instructions
To earn CME credit, you must read the article in Emergency Medicine News, and complete the evaluation questions and quiz, answering at least 80 percent of the questions correctly. Mail the completed quiz with your check for $12 payable to Lippincott Continuing Medical Education Institute, Inc., Two Commerce Square, 2001 Market St., Third Fl., Philadelphia, PA 19103. Only the first entry will be considered for credit, and must be received by Lippincott Continuing Medical Education Institute by July 31, 2011. Acknowledgment will be sent to you within six to eight weeks of participation.
Lippincott Continuing Medical Education Institute is accredited by the Accreditation Council for Continuing Medical Education to provide medical education to physicians. Lippincott Continuing Medical Education Institute designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit.™ Physicians should only claim credit commensurate with the extent of their participation in the activities.
Luis M. Lovato, MD, an Associate Professor at the David Geffen School of Medicine at UCLA, the Director of Critical Care in the Department of Emergency Medicine at Olive View-UCLA Medical Center, and an instructor for the National MegaLLSA Review Course (www.megallsa.com), serves as the medical editor of this column.