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The second edition of this detailed guide to the diagnosis and treatment of common plastic surgery emergencies includes updated clinical information on the most common emergency situations. This book gives plastic surgeons, as well as any physicians who may encounter emergency plastic surgery issues, the basic skills they need to effectively treat their patients and to ultimately be successful in their practice.

Key Features of the Second Edition:

  • New chapter covering sternal wounds
  • Easy-to-follow color diagrams demonstrating key procedures and full-color photographs for rapid diagnosis

Plastic Surgery Emergencies is an indispensable resource for clinicians, residents, and trainees in plastic surgery. It is also ideal for all emergency room personnel, including ER physicians, physicians' assistants, and nurse practitioners, as well as family practice physicians.

Year:
2017
Edition:
2
Publisher:
Thieme
Language:
english
Pages:
304 / 288
ISBN 10:
162623115X
ISBN 13:
9781626231153
File:
PDF, 10.83 MB
Download (pdf, 10.83 MB)

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Plastic Surgery Emergencies
Principles and Techniques
Second Edition

Jam al M. Bu llock s, MD, FACS
Ch ief
Plast ic Su rger y Dep ar t m en t
Kelsey-Sybold Clin ic
Clin ical Assistan t Professor
Division of Plast ic Surger y
Baylor College of Medicin e
Hou ston , Texas, USA
Pat r ick W. Hsu , MD, FACS
Private Pract ice
Mem orial Plast ic Su rger y
Hou ston , Texas, USA

Sh ayan A. Izad d oost , MD, Ph D, FACS
Ch ief of Plast ic Su rger y
Ben Taub Hospit al
Associate Professor of Su rger y
Baylor College of Medicin e
Program Director
In tegrated Residen cy in Plast ic an d
Recon st ruct ive Su rger y
Associate Professor of Molecu lar
an d Cellular Biology
Baylor College of Medicin e
Hou ston , Texas, USA
Lar r y H. Hollier, Jr., MD, FACS, FAAP
Ch ief
Plast ic Su rger y Ser vice
Texas Ch ildren’s Hosp ital
Ch ief of Plast ic Su rger y
Baylor College of Medicin e
Baron Hardy Ch air an d Professor
Plast ic Su rger y an d Pediat rics an d
Or th opedics
Baylor College of Medicin e
Hou ston , Texas, USA

150 illu st rat ion s

Th iem e
New York • St u t tgar t • Delh i • Rio de Jan eiro

Execu t ive Editor: Tim othy Hiscock
Man aging Ed itor: Elizabeth Palu m bo
Director, Ed itorial Ser vices: Mar y Jo Casey
Product ion Editor: Torsten Sch eihagen
In tern at ion al Produ ct ion Director:
An dreas Schaber t
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Sarah Van derbilt
Presiden t: Brian D. Scan lan
Library o f Co ngress Catalo ging-in-Publicatio n Data
Nam es: Bu llocks, Jam al M., au th or.
Title: Plast ic su rger y em ergen cies / Jam al M. Bu llocks,
MD, FACS, Ch ief,
Plast ic Surger y Depar t m en t , Kelsey-Seybold Clin ic,
Clin ical Assist an t
Professor, Division of Plast ic Surger y, Baylor College
of Medicin e,
Houston , TX [and th ree oth ers].
Descript ion : Secon d ed it ion . | New York, NY : Th iem e
Medical Pu blish ers,
In c.,;  [2016] | Revision of: Plast ic su rger y
em ergencies / Jam al M.
Bullocks ... [et al.]. c2008.
Id en t ifiers: LCCN 2016016016 (p rin t) | LCCN
2016016879 (ebook) | ISBN
9781626231153 (prin t) | ISBN 9781626231160
(eISBN) | ISBN 9781626231160
(e-book)
Su bject s: LCSH: Su rger y, Plast ic. | Surgical em ergencies.
Classificat ion : LCC RD118 .P5363 2016 (p rin t) | LCC
RD118 (ebook) | DDC
617.9/52--dc23
LC record available at h t t p s://lccn .loc.gov/2016016016

© 2017 Th iem e Medical Publish ers, In c.

Im p or t an t n ote: Medicine is an ever-changing
scien ce un dergoing con tin ual developm en t. Research
an d clin ical exp erien ce are con t in u ally expan ding
ou r kn ow ledge, in part icu lar ou r kn ow ledge of
proper treatm ent and drug th erapy. Insofar as this
book m ent ions any dosage or applicat ion, readers
m ay rest assured that the authors, editors, and
publishers h ave m ade ever y effor t to ensure that
su ch referen ces are in accordan ce w ith t h e st ate of
k n ow ledge at t h e t im e of p rod u ct ion of th e book.
Neverth eless, this does n ot involve, im ply, or
express any gu aran tee or respon sibilit y on th e
par t of the publishers in respect to any dosage
instruct ions and form s of applications stated in the
book. Ever y u ser is requ ested to exam in e carefu lly
the m anufact urers’ leaflets accom panying each drug
an d to ch eck, if n ecessar y in con su ltat ion w ith a
physician or specialist, w hether the dosage schedules
m entioned therein or the cont raindications stated by
the m anufact urers differ from the statem ents m ade
in the present book. Such exam ination is par ticularly
im portant w ith drugs that are either rarely used or
h ave been n ew ly released on th e m arket. Ever y
dosage sch edu le or ever y form of application used is
ent irely at the user’s ow n risk an d respon sibilit y. Th e
au th ors an d pu blish ers requ est ever y u ser to report
to th e publishers any discrepan cies or in accu racies
n ot iced. If errors in this w ork are fou n d after
publication, errata w ill be posted at w w w.thiem e.
com on the product descript ion p age.
Som e of th e product nam es, patents, an d
registered design s referred to in th is book are in fact
registered tradem arks or proprietar y nam es even
th ough specific reference to th is fact is n ot alw ays
m ade in the text. Therefore, the appearance of a
nam e w ithout designation as proprietar y is not to be
construed as a representation by the publisher that it
is in th e public dom ain.

Th iem e Publish ers New York
333 Seven th Aven ue, New York, NY 10001 USA
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ISBN 978-1-62623-115-3
Also available as an e-book:
eISBN 978-1-62623-116-0

54321

This book, in clu ding all p ar t s th ereof, is legally
protected by copyrigh t . Any use, exploit at ion, or
com m ercializat ion ou t sid e th e n arrow lim it s set
by copyrigh t legislat ion , w ith ou t th e pu blish er’s
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applies in par t icular to ph otostat reproduct ion ,
copying, m im eograp h ing, preparat ion of m icrofilm s,
and elect ronic data processing an d storage.

It is w ith great pleasure that I dedicate the new est edit ion of our text to our senior author, Dr. Sam uel Stal. Sam died several years ago after a lengthy illness.
He w ould have been m ost pleased to see that this w ork has stood the test of
t im e. Sam w as a surgeon w ho dedicated his life to the t reat m ent of children. He
w as passionate about teaching and passing on all that he had learned through
the years. He w as a m entor to all of us w ho w orked w ith him on this book and
he w as inst rum ental in seeing the first edit ion through to publicat ion. I know
that I can speak for all of m y coauthors, and thank Sam for being the person
that he w as—an excellent teacher, but first and forem ost, a k indhearted and
caring m an.
—Larry H. Hollier, MD

Contents

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

Forew ord ...........................................................................................................
Preface ...............................................................................................................
Ack n ow ledgm en t s ..........................................................................................
List of Ab b reviat ion s ......................................................................................

ix
xi
xi
xiii

Wou n d Man agem en t .....................................................................................
An est h esia an d Wou n d Closu re ..................................................................
Pressu re Sores ..................................................................................................
Bit e Wou n d s .....................................................................................................
Bu r n s an d Frost b ite ........................................................................................
Gen eral Assessm en t an d Man agem en t of Facial Trau m a ....................
Facial Lacerat ion s ...........................................................................................
Or b it an d Zygom a Fract u res ........................................................................
Nasal an d Naso -Or b it al-Et h m oid (NOE) Fract u res ................................
Fron t al Sin u s Fract u res .................................................................................
Man d ib u lar Fract u res ....................................................................................
Exam in at ion of Han d In ju r ies .....................................................................
An est h esia an d Sp lin t in g of t h e Han d an d Wr ist ...................................
Han d an d Wr ist Fract u res an d Dislocat ion s ............................................
Han d In fect ion s an d In ject ion In ju r ies .....................................................
Han d an d Forear m Ten d on In ju r ies ...........................................................
Han d Vascu lar In ju r ies an d Digit Am p u t at ion s ......................................
Up p er Ext rem it y Per ip h eral Ner ve In ju r ies ............................................
Up p er Ext rem it y Com p ar t m en t Syn d rom e .............................................
Postop erat ive Evalu at ion of Free Flap Recon st r u ct ion s .......................
Th e Postop erat ive Aest h et ic Pat ien t ..........................................................
Ster n al Wou n d s ...............................................................................................

1
8
16
20
32
63
76
88
99
109
114
126
138
148
174
196
207
217
222
229
238
252

In d ex .................................................................................................................. 256

vii

Forew ord from the First Edition
“Th e m an w h o gradu ates today an d stops learn ing tom orrow is un edu cated th e day after.”
—New ton D. Baker Jr.

W hen I w as asked to w rite a foreword for this
book Plastic Surgery Em ergencies, I m ust confess, m y first thought was, “Is anoth er book
truly necessary?” But after reading it , I am
both h onored and flat tered by th e request .
The brow ser m ight first question if th is relatively sm all book fulfills a need, an d second
ask if it fulfills the need well. The answer to
both questions is a resoun ding “Yes.”
With the body of m edical know ledge doubling every 5 years or so, th e in form at ion
that m ust eith er have been learned or be
readily available and understandable to both
the young as well as th e experienced plast ic
surgeon continues to increase exponentially.
This book distills presen t know ledge into an
easily readable guide to alm ost any em ergency a plastic surgeon m ight face w ho is on call
in the em ergency room , or responding to a
late-night/early-m orning call from the hospital relating to a postoperative patien t.
Th e au th ors, w h o are gen eral p last ic su rgeon s an d specialist s from th e Division of
Plast ic Surger y h ere at t h e Baylor College
of Medicin e, h ave cu lled in form at ion from
th eir ow n su rgical exp erien ces, as w ell as a
w id e variet y of ou t side sou rces. Th ey h ave
con den sed th is kn ow ledge in to a sm all,
h an dy volu m e, w h ich cou ld easily be read
eit h er at on e’s leisu re or im m ediately prior
to assu m ing th e care of a p at ien t . It w ou ld
be difficult to fin d an injur y or com plicat ion from a plast ic su rger y operat ion w hose
em ergen cy t reat m en t is n ot covered in th is
book. Th e aut hors h ave det ailed th e specifics in term s of differen t ial diagn osis an d
th e correct ive steps n ecessar y to fu lfill th e
respon sibilit ies of a plast ic su rgeon an sw e-

ring em ergen cy room call. Th ere are m any
referen ces to th e gen eral prin ciples of t reat m ent s—th ose learn ed in residen cy t rain ing
an d in th e early years of p ract ice th at h ave
stood th e test of t im e. Th e abilit y of t h e surgeon to presen t an organ ized t reat m en t plan
an d th en carr y it ou t exp ed it iou sly w ill in st ill con fiden ce in th e pat ien t an d th e h ealth
care person n el involved in t h e t reat m en t
of th ese p at ien t s. Th e form at of th e book is
con du cive to allow ing readers to add both
person al an d tech n ical notes, w h ich w ill
ser ve th em w ell in th e t reat m en t of fut u re
pat ien t s w ith sim ilar injuries.
I w ou ld be rem iss if I did n’t call sp ecial at ten t ion to t he lead au th or, Dr. Jam al M. Bullocks, w h ose abilit y an d you t h fu l en th u siasm
h as am algam ated th e th ough t s an d exp erien ce of th e oth er auth ors in to a volum e th at
w ill fin d great valu e for all plast ic su rgeon s
as w ell as gen eral su rgeon s an d em ergen cy
room physician s.
To those older plast ic surgeon s w h o m ay
believe that they have already learned the
an swers to m ost of the problem s presen ting
to th e plastic surgeon on call, I respectfully
suggest that although the problem s that presented a decade or t wo ago m ay be the sam e,
the answers (i.e., treatm ent) today m ay be
different. It is to that difference that we are
indebted to the authors of this book for their
effort and tim e in providing us w ith concise
an d practical an swers.
Melvin Spira, MD, DDS
Division of Plast ic Surgery
Depart m ent of Surgery
Baylor College of Medicine

ix

Preface
Th e goal in creat ing Plast ic Surgery Em ergencies is to provide a quick referen ce gu id e for
h ealth care p roviders to rapid ly assess, t riage, an d t reat pat ient s w ith problem s th at are
com m on ly referred to th e p last ic su rgeon .
Th e first version t argeted acu te care scen arios com m on ly seen in th e em ergen cy dep ar tm en t of acutely injured facial and han d t raum a pat ien t s, as w ell as pat ien t s sust ain ing a
variet y of soft-t issu e inju ries from var ying
m ech anism s of t raum a, in cluding burn s. Th is
n ew ed it ion provides th e reader w ith addit ion al con ten t , in cluding added chapters,
p h otos, an d sect ion s w h ich w ill expan d th e
book’s audience to out pat ien t an d h ospit albased physician s caring for ch ron ically ill
p at ien t s w ith w ou n ds. Th e in form at ion presen ted w ill prove sign ificant ly ben eficial to
p last ic su rgeon s, otolar yngologist s, derm atologist s, p ediat rician s, fam ily p ract ice, an d

h ospit alist an d em ergen cy room p hysician s
for t reat ing an d t riaging p at ien t s in th e acu te an d ch ron ic disease set t ing. Ult im ately,
th e aim is to d em yst ify sim p le p roblem s
th at p resen t to th ese providers an d elu cidate scen arios th at require a h igh er level
of care or follow -u p w it h a p last ic su rgeon .
Ou r in ten ded au dien ce addit ion ally exten ds
to residen t s an d st u den t s t rain ing in th ese
fields w h o exp erien ce th ese en cou n ters as
con sult at ion s an d du ring on -call act ivit y.
Th e out line form at w as preser ved w ith
t run cated in t roductor y vern acular to con fer
direct m ech an ism s for in st ruct ion s on h ow
to w ork u p, categorize, an d in it iate th e first
level of t reat m en t . We h ope th at th is focused
an d sim p lified p resen t at ion w ith in st r u ct ive
illust rat ion s, ch ar t s, an d diagram s w ill provid e a single-sou rce referen ce in a conven ient pocket-sized form at .

Acknow ledgments
Plast ic Surgery Em ergencies is a collection of
the collaborative kn ow ledge and experien ce
of all th e affiliated and full-tim e facult y of
the Division of Plastic Surgery in the Mich ael
E. Debakey Departm ent of Surger y at Baylor College of Medicine. The authors would
also like to express th eir gratit ude to the
residents, staff, and institut ions of the Texas
Medical Center for th eir support in the com pletion of this work.
Illustrato r: Mike d e la Flor
Cover Illustrato r: Cara Ryan Dow n ey, MD

xi

List of Abbreviations
3D
ABCs
ABGs
ACON
ACS
AFib
AP
APB
APD
APL
APTT
ASA
BP
BSA
BSAB
CBC
Ch em -7
CK
CMC
CML
CN
COPD
CRP
CSF
C-spin e
CT
CVP
CXR
D5 1/2NS
DIC
DIEAP
DIP
DISI
DJD
DRU
DVT
EBL
ECRB
ECRL
ECU
EDC
EDM
EIP
EMG
EMLA
ENoG
ENT
EPB
EPL
ER
ESR
FCR
FCU
FDA
FDM
FDP
FDS
FFP
FPB
FPL

th ree-dim en sion al
air w ay, breathing, and circu lat ion
ar terial blood gases
acute com pressive opt ic n europ athy
abdom inal com par t m en t syn drom e
at rial fibrillat ion
an teroposterior
abdu ctor pollicis brevis
afferen t p upillar y defect
abdu ctor pollicis longu s
act ivated PTT
asp irin
blood p ressure
body surface area
body surface area burn ed
com p lete blood coun t
a basic m et abolic pan el
creat in e kin ase
carpom et acarp al
carpom et acarp al ligam ent
cran ial ner ve
ch ronic obst ruct ive pu lm onar y disease
C-react ive protein
cerebrospin al fluid
cer vical spin e
com p uted tom ography
cen t ral venou s pressure
ch est X-ray
5% dext rose in 0.45% n orm al saline
dissem in ated in t ravascu lar coagu lat ion
deep in fer ior ep igast ric ar ter y perforator flap
dist al interp halangeal
dorsal in tercalated segm ent in st abilit y
degen erat ive join t disease
dist al radiouln ar
deep venous throm bosis
est im ated blood loss
exten sor carpi rad ialis brevis
exten sor carpi rad ialis longus
exten sor carpi ulnar is
exten sor d igitor um com m u n is
exten sor digit i m in im i
exten sor in dicis p roprius
elect rom yogram
eu tect ic m ixt u re of local an esth et ics
elect ron euron ography
ear, n ose, an d th roat
extensor pollicis brevis
exten sor p ollicis longus
em ergen cy room
er yth rocyte sedim ent at ion rate (or sed rate)
flexor carpi radialis
flexor carpi uln aris
Food an d Drug Adm inist rat ion
flexor digit i m inim i
flexor d igitor um profu ndus
flexor d igitor um sup erficialis
fresh frozen plasm a
flexor pollicis brevis
flexor pollicis longu s

xiii

GCS
Hct
HDCV
Hgb
I&D
ICU
IM
INR
I/Os
IP
IRV
IV
IVF
JP
JVD
LDH
LET
LFT
LR
MAP
MCP
MMF
MRI
MRSA
MVA
NCS
NOE
NPO
NS
NSAID
OOB
OR
ORIF
OTC
PA
PDS
PEEP
PIP
PL
PNM
POD
PRBCs
PT
PTT
RBBB
RBC
RIG
ROM
RR
SBP
SC
SCM
SSEP
SMAS
SOF
STAT
TBSA
Tc 99m MDP
Td
TFCC
TIG
TMJ
TON
TPA

xiv

Glasgow Com a Scale
hem atocrit
hu m an diploid cell rabies vaccin e
hem oglobin
incision an d d rain age
in ten sive care unit
int ram uscu lar or in t ram u scularly
in tern at ion al nor m alized rat io
in t akes/ou t p u ts
in ter ph alangeal
inverse rat io ven t ilat ion
int ravenou s or in t raven ou sly
int ravenou s fluid
Jackson -Prat t
jugu lar ven ous distent ion
L-lactate d ehydrogen ase
lidocain e-epin eph rin e-tet racain e
liver fun ct ion test
lactated Ringer's
m ean ar terial pressure
m et acarp op h alangeal
m axillom an dibu lar fixat ion
m agn et ic reson an ce im aging
m eth icillin -resistan t Staphylococcus aureus
m otor vehicle accid en t
n er ve con du ct ion st udies
n aso-orbit al-eth m oid
noth ing by m outh
norm al salin e
n on steroidal an t i-in flam m ator y drug
ou t of bed
operat ing room
op en red uct ion and inter nal fixat ion
over-the-counter
posteroan terior
polyd ioxan on e sut ure
posit ive en d-exp irator y pressure
proxim al in terph alangeal
palm aris longu s
polyn uclear m on ocyte
postop erat ive day
packed red blood cells
proth rom bin t im e
p ar t ial throm boplast in t im e
righ t bun dle bran ch block
red blood cell
rabies im m un oglobulin
range of m ot ion
respirator y rate
systolic blood pressu re
su bcut an eous or su bcu tan eou sly
stern ocleidom astoid
som atosen sor y evoked poten t ial
su perficial m uscu loaponeu rot ic system
su perior orbit al fissure
at on ce, im m ediately
total body su rface area
tech n et ium 99m m ethylen e d isph osph on ate
tetanus toxoid
t riangular fibrocart ilage com plex
tetanus im m unoglobulin
tem porom an dibular joint
t rau m at ic opt ic n europ athy
t issue plasm in ogen act ivator

TPN
TRAM
TSST-1
UC
VDR
VISI
W BC
ZMC

tot al paren teral nu t rit ion
t ran sverse rect u s abdom inis m yocut an eou s flap
toxic sh ock syn drom e toxin -1
ulcerat ive colit is
volu m e diffusive respirator
volar in tercalated segm en t in st abilit y
w h ite blood cell
zygom at icom axillar y com plex

xv

1

Wound Management

Evaluation
Accurate assessm ent of the ch aracteristics of an d circum stan ces surroun ding th e presentation of w oun ds is critical to guiding treatm en t strategies. Th erefore, before w ound m an agem ent is plan ned, a full evaluation
of th e w oun d m ust be undertaken w ith the follow ing con siderations.

Acute Wounds
• Assess size, sh ape, an d locat ion .
• Determ in e th e t im ing of th e w ou n d—acu te (t im e elap sed sin ce
injur y) versu s ch ron ic (persisten t > 3 m on th s).
• Est ablish lacerat ion , avu lsion , or ch ron ic open w ou n d.
• Evaluate th e w ou n d for odor, exu date, p u ru len t drain age, bleeding,
an d debris.
• Determ in e if th ere is exp osu re of vessels, ten don s, n er ves, join t ,
m uscle, or bon e.
• Evaluate for foreign bodies in th e w ou n d; con sider X-ray
evaluat ion —if th e h istor y is in con sisten t w ith clin ical evaluat ion .

Chronic Wounds
Ch ron ic w oun ds require invest igat ion in to reason s w hy proper w oun d
h ealing is n ot accom plish ed (Table 1.1).
Th erefore, ch ron ic w ou n ds w arran t serologic evalu at ion to in clu de
•
•
•
•
•
•
•
•
•
•

W h ite blood cou n t .
Hct/Hgb.
Albu m in .
Prealbu m in .
ESR, or sed rate.
C-react ive p rotein .
LFTs, h ep at it is p an el.
Blood glu cose.
Biopsy of w ou n d.
Cult u re of w oun d.
1

2 Wound Managem ent

Table 1.1

Contributors to poor wound healing

Local factors that contribute to
poor w ound healing

Patient comorbid conditions that
contribute to poor w ound healing

Tissue ischem ia
Venous hypertension
Edem a
Infection
Microbial contam ination
Bacterial > 10 5 or 10 4 group
B Streptococcus species
Fungus
At ypical mycobacteria

Anem ia
Hypoxia
Advanced age
Malignancy
Poor nutrition
Vitam in de ciencies
History of radiation
Severe system ic disease
(e.g., diabetes, hepatic disease)
Collagen vascular diseases

Wound tension or pressure > 30 m m
Hg
Presence of foreign bodies

Im m unosuppression
Smoking
Obesit y

Treatment
Irrigation
Acute Wounds
Irrigat ion in th e acu te w ou n d set t ing is design ed to rem ove blood,
foreign bodies, debris, an d bacteria from a w oun d. Th is can easily be
accom plish ed w ith a 1-L bot tle of n orm al salin e w ith t w o or th ree h oles
pu n ch ed in to th e cap w ith an 18-gauge n eedle. W h en squ eezed forcefully, it ser ves as an e ect ive pressu rized irrigator. Th e w oun d sh ould
be irrigated u n t il all visible debris is w ash ed aw ay. An esth et izing th e
w ou n d p rior to irrigat ion an d débridem en t p rovides for greater p at ien t
com for t an d allow s for aggressive decon tam in at ion of th e w ou n d.

Chronic Wounds
Sim ple surface irrigation of a chronic w oun d is usually only m arginal
and m inim ally e ective. It can be useful at the bedside if there is debris
grossly evident in the wound. Studies have show n that pressure irrigation
at approxim ately 70 psi is needed to reduce bacteria count and particulate

Wound Managem ent 3

m at ter. This is best done in the operating room w ith a pulse lavage or a
jet lavage system . If needed, a thorough débridem ent of devitalized tissue can also be done in the operating room . Tangential hydrotherapy via
the Versajet (Sm ith & Nephew ) device is often useful for irrigation and
m echanical débridem ent. A chronic w ound m ay bene t from biopsy and
tissue culture as clinically indicated.

Débridement and Hemostasis
Adequate débridem ent of devitalized tissue and skin edges is im portant in
preparing the contam inated wound for closure. The skin is highly vascular
and excessive skin rem oval is usually not necessary. Jagged skin edges should
be trim m ed to facilitate an easier closure. Hem ostasis can be achieved w ith
pressure, silver nitrate, topical brin, Surgicel (Johnson & Johnson), topical
throm bin or epinephrine (1:100,000), suture ligature (absorbable for sm all
vessels and nonabsorbable for larger vessels), or cautery (Fig. 1.1).
If th ere is any qu est ion as to th e viabilit y of th e t issue, it is bet ter to
allow the t issu e to dem arcate rath er th an to débride it init ially. Tissue of
qu est ion able viabilit y can often u n dergo n ecrosis after débridem en t du e
to ret rograde throm bosis. On ce dem arcated, th e t issue can be débrided to
h ealthy bleeding t issue. Th is approach allow s conser vat ive preser vation
of th e tissu es w ith out cau sing addit ion al t issu e loss an d dis guration.

Fig. 1.1 Useful tools for establishing hemostasis in acute wound m anagem ent: (a) topical
epinephrine diluted to 1:100,000, applied with gauze, (b) topical thrombin spray, (c) oxidized m ethylcellulose (Surgicel), (d) coagulation with silver nitrate, or (e) disposable portable cautery device.

4 Wound Managem ent

Closure and Antibiotics
Prior to closu re, irrigat ion , d ébridem en t , h em ost asis, an d t rim m ing of
th e skin’s jagged edges sh ou ld be perform ed. A ten sion -free closure w ill
h elp to en su re h ealing w ith an opt im al scar.
Most clean lacerat ion s, if ad dressed in < 8 h ou rs, h ave m in im al con tam in at ion an d can be closed prim arily w ith out th e n eed for an t ibiot ics.
Clean w ou n ds presen t ing after 8 h ou rs can be closed after débridem en t
of th e en t ire w oun d an d sh arp débridem en t of edges. Th is w ould in clude
st ab w ou n ds, lacerat ion s by w in dow or glass, an d clean avu lsion s. In
e ect , sh arp débridem en t an d decon t am in at ion of th ese late presen t ing
w ou n ds convert s th em in to fresh w ou n d s th at are m ore app rop riate for
closu re. On th e oth er h an d, con t am in ated w ou n d s, su ch as w ou n ds w ith
dir t an d debris, sh ou ld be t reated w ith system ic an t ibiot ics w ith ad dit ion al con siderat ion for tetan u s p rop hylaxis.
Ch oice of an t ibiot ics sh ou ld u su ally cover gram -p osit ive organ ism s
(cefazolin 1 g IV). Due to th e in crease in m eth icillin -resistan t Staphylococcus aureus (MRSA), cer tain w oun ds m ay require oth er an t ibiot ics
for coverage (clin dam ycin 600 m g IV or van com ycin 1 g IV). Th e ast u te
caregiver sh ou ld t ake advan t age of adm in ist rat ion of a single IV dose of
an t ibiot ics to w oun ds at risk for con t am in at ion w h ile th e pat ien t is in a
h ealth care set t ing un dergoing evalu at ion .
If th e w ou n d is grossly con t am in ated w it h debris or if th e p at ien t is
diabet ic, broader-sp ect ru m an t ibiot ics sh ou ld be con sidered, for exam ple, Avelox (Bristol-Myers Squ ibb) 400 m g IV or by m outh daily, Zosyn
(Wyeth Ph arm aceu t icals) 3.375 g IV ever y 6 h ours, im ipen em 1 g IV
ever y 8 h ou rs, or com bin at ion th erapy.
Con tam in ated w ou n ds sh ou ld be left op en except for th ose on th e
face. Wet to dr y dressing ch anges sh ou ld be don e at least t w ice a day.
In addit ion , th e p at ien t sh ou ld sh ow er frequ en tly an d w ash th e w ou n d
w ith soap an d w ater.
A 5- to 7-day cou rse of ou t p at ien t an t ibiot ics m ay also be w arran ted. Coverage sh ou ld in clude gram -p osit ive an d MRSA coverage (oral
clin dam ycin 450 m g by m outh fou r t im es a day, or oral t rim eth oprim /
su lfam eth oxazole t w ice a day). Cep h alexin is n ot e ect ive in t reat ing
a con tam in ated w ou n d. Rarely, acu te w ou n ds w ill requ ire inpat ien t
t reat m en t w ith IV an t ibiot ics. Usu ally débridem en t an d prophylact ic
oral an t ibiot ics sh ould su ce. In th e case of m ore subacu te or ch ron ic
w ou n ds w ith gross con t am in at ion or p u ru len ce, con siderat ion sh ou ld
be given to adm ission , IV an t ibiot ics, an d form al débridem en t .

Wound Managem ent 5

Skin-Flap Wound Closure
If th e p at ien t h as an avu lsed skin ap, th e ap sh ould be tacked dow n
w h ere it lies (Fig. 1.2). Do not put tensio n o n the skin ap fo r co m plete clo sure . Ten sion w ill lead to tot al ap loss. First , débride all devit alized t issu e an d th en in set th e ap so th at n o ten sion is presen t . Dist al
m argin s of th e ap w ill usually un dergo n ecrosis. Plan on addit ion al
débridem en t as th e ap dem arcates.

Tetanus Prophylaxis
Tetan u s-p ron e w ou n ds are th ose th at are old (> 6 h ou rs), d eep (> 1 cm ),
an d/or con tam in ated, especially th ose th at involve ru st y m et al, feces, or
soil. Depen ding on t h e degree of con tam in at ion , tet an us toxoid, tet an u s im m un oglobulin , or com plete im m un izat ion m ay be required. Speci c recom m en dat ion s for tet an us prophylaxis are in cluded in Table 1.2
th rough Table 1.4.

Fig. 1.2

(a) Avulsed skin ap. (b) Avulsed skin ap tacked down without tension.

6 Wound Managem ent

Table 1.2

Tetanus-prone wounds

Clean (low risk)

Tetanus prone (high risk)

Clean incised wound

Any wound or burn > 6 h old

Super cial graze

Contact with soil, feces, compost, or
saliva

Scalded skin

Puncture-t ype wound
Avulsion wounds
Crush open wounds
Infected wound
Compound fracture
Large am ount of devitalized tissue
Anim al or hum an bite
Burns and frostbite

Table 1.3

Im munization status and tetanus risk

Immunization status

Low risk

Moderate risk

High risk

Fully im m unized, < 5 y
since booster

None

None

None

Fully im m unized, 5–10 y
since booster

None

Td

Td

Fully im m unized, > 10 y
since booster

Td

Td

Td + TIG

Incompletely imm unized or
uncertain

Full tetanus
vaccine

Full tetanus
vaccine + TIG

Full tetanus
vaccine + TIG

Abbreviations: Td, tetanus toxoid; TIG, tetanus im m unoglobulin.

Wound Managem ent 7

Table 1.4

Recom m endations for vaccination with tetanus im m unoglobulin

Patient

Dosage

Treatment

Adult

250–500 U

For both patient groups, the
vaccine should be given IM in
the opposite upper extrem it y
(arm ) to the tetanus toxoid

Pediatric

250 U

Follow -up
Carefu l an d frequ en t follow -u p is im perat ive for all w oun ds. Pat ien ts
sh ould be asked to ret u rn to th e clin ic or gen eral p ract it ion er w it h in
3 days if p ossible an d edu cated on all th e sign s an d sym ptom s of an
in fect ion . Speci c in st ru ct ion s on w oun d care an d an t ibiot ic th erapy are
cru cial to gu aran teeing pat ien t com p lian ce an d u lt im ately a favorable
progn osis.

2

Anesthesia and Wound Closure

All wounds should be clean of foreign bodies and adequately irrigated (see
Chapter 1). Hem ostasis is achieved w ith pressure, silver nitrate, brin, Surgicel, throm bin, or suture ligature (absorbable for sm all vessels and nonabsorbable for larger vessels) to prevent hem atom a form ation. Any devitalized
tissue, as well as jagged edges, should be trim m ed for optim al cosm esis.
Wounds can be closed w ith sut ures, staples, skin tapes, or w ound
adhesives. Generally, w ounds should be closed in layers using appropriate
sut ures an d the epiderm is reapproxim ated so that it is relatively tension
free and everted if possible. Everted skin edges event ually atten out and
produce a level w ound surface, w hereas inverted skin edges have a tendency to produce a depressed scar.
To guaran tee a successfu l w oun d closure, a com for table environ m en t
sh ou ld be created for both th e p ract it ion er an d th e p at ien t . Th e u se of
an algesics, local an esth esia, an d even sedat ion are h elpfu l adjun ct s in
redu cing p at ien t an xiet y. Th is w ill u lt im ately in crease th e likelih ood of
m ore precise closu re.

Anesthesia
Local Anesthetics
Local an esth et ics w ork by a ect ing th e sodium (Na +) ch an n els on a eren t sen sor y n er ves. Local an esth et ic en ters th e cell m em bran es an d
reversibly bin ds to Na + ch an n els. Th is reversible bin ding in cap acit ates
th e cells so th at th ey are th en u n able to d ep olarize. Lid ocain e is t h e m ost
com m on ly u sed an d easily accessible local an esth et ic agen t in t h e em ergen cy room (ER). Epin eph rin e sh ould rout in ely be u sed w ith any local
an esth et ic to assist in h em ost asis an d to prolong durat ion . Th e vasocon st rict ive p roper t ies lead to decreased absorpt ion so th at larger doses of
an esth et ic can also be used w ith ou t system ic toxicit ies.
Th e m a xim u m safe dose for lidocain e is 4 m g/kg. With th e ad dit ion
of epin eph rin e (usually at 1:100,000 con cen t rat ion ), th e m axim um dose
in creases to 7 m g/kg. A 1% solu t ion of lidocain e is de n ed as

8

1 g/100 m L = 10 g/1,000 m L = 10,000 m g/1,000 m L = 10 m g/1 m L
Exam ple Maxim um dose of lidocaine w ith epinephrine in a 70-kg
(154-lb) m an

Anesthesia and Wound Closure 9

70 kg × m a x dose (7 m g/kg) = 490 m g of lidocain e
490 m g × 1 m L/10 m g (con cen t rat ion of 1% lidocain e) = 49 m L of 1%
lidocain e w ith epin eph rin e
Alth ough m any textbooks h ave cited th e con t rain dicat ion for u sing
epin eph rine in en d ar teries such as th ose in digit s an d th e n ose, recen t
st udies h ave exon erated epin eph rin e as th e culprit in causing t issue
n ecrosis. Therefore, it is safe to use lidocain e w ith epin eph rin e virt ually
anyw h ere on th e body. For th e m axim u m e ect s of epin eph rin e to take
place, th e pract it ion er sh ould w ait 10 to 15 m in utes. Table 2.1 provides
oth er local an esth et ics th at m ay be used, w ith th eir m a xim u m dosages
an d durat ion of act ion .
Once you have chosen your local anesthetic, it is useful to add bicarbonate to the solution, particularly w hen the patient is awake. The pH of
local anesthetic solutions is generally bu ered to bet ween 4 and 5 to prolong shelf life. This acidit y routinely leads to a burning pain upon injection.
Adding a base such as bicarbonate to the local anesthetic not only alleviates
the pain but also accelerates the action because the higher pH favors the
nonionized form of the anesthetic, w hich crosses the cell m em brane m ore
easily. The addition of 1 m L of a 1-m Eq/m L solution of bicarbonate for every
9 m L of local anesthetic can alleviate the burning and im prove patient com fort. Warm ing the anesthetic, using a sm aller-caliber needle (25 gauge or
higher), and injecting by inserting the needle w ithin the wound (instead of
through the skin) all help in reducing pain felt by the patient.
Table 2.1

Local anesthetics for wound closure

Drug

Onset

Maximum dose mg/kg
(w ith epinephrine mg/kg)

Duration (w ith
epinephrine)

Lidocaine

Rapid

4.5 (7)

120 m in (240 min)

Mepivacaine

Rapid

5 (7)

180 m in (360 m in)

Bupivacaine

Slow

2.5 (3)

4 h (8 h)

Procaine

Slow

8 (10)

45 min (90 m in)

Chloroprocaine

Rapid

10 (15)

30 m in (90 m in)

Etidocaine

Rapid

2.5 (4)

4 h (8 h)

Prilocaine

Medium

5 (7.5)

90 m in (360 min)

Tetracaine

Slow

1.5 (2.5)

3 h (10 h)

10 Anesthesia and Wound Closure

Topical Anesthetics
• Eutect ic m ixt ure of local anesthet ics (EMLA): 2.5% prilocain e an d 2.5%
lidocain e cream .
• Lidocaine-epinephrine-tetracaine (LET) gel: 4% lidocain e, 1:2,000
ep in eph rin e, 1% tet racain e.
Top ical an esth et ics are m ore com m on ly u sed in th e p ediat ric pat ien t to
alleviate th e pain associated w it h local inject ion s. Alth ough e ect ive,
th ey are n ot n early as e ect ive as local an esth et ic in lt rat ion in providing an esth esia. Th e du rat ion an d depth of th e blockade is dep en den t on
th e am ou n t of t im e th e cream is in con t act w ith th e skin . App ly to th e
w oun d an d th en cover w ith a Tegaderm (3M) or oth er occlusive dressing. Th e cream or gel w ill u su ally n eed to be in place for at least 45 m in utes before any an esth et ic e ect is ach ieved.

Digital and Facial Nerve Blocks
Please see respective chapters: Upper Extrem it y Injuries (Chapter 18) and
Facial Traum a (Chapter 8).

Conscious Sedation
Most sim ple and even m oderately com plex laceration s can be repaired
w ith relative ease w ith local anesthetics alone in the adult patient. How ever, fear and anxiet y are com m on in the pediatric patien t. Th erefore,
it m ay be di cult to repair a laceration in th e understandably un coop erative pediatric patient. Conscious sedation m ay be used if conditions
are appropriate and the necessar y precautions follow ed. A w ell-trained
pediatrician or anesthesiologist should be consulted for adm inistration of
conscious sedation, especially if the surgeon’s experience is lim ited in this
eld. Full m onitoring by a nurse is required throughout the procedure.
Prior to adm in istering con sciou s sedat ion , a com p lete h istor y an d
physical exam in at ion sh ou ld be obtain ed , in clu ding
•
•
•
•
•
•
•

Age.
Weigh t (m easu red, n ot est im ated, w h en ever possible).
Vit al sign s.
Oxygen sat urat ion .
Absen ce of h ead injur y (docu m en t).
Hear t , lu ng, n eu rologic, an d m en t al stat u s.
Com p lexit y an d locat ion of injur y.

Anesthesia and Wound Closure 11

Prior to sedat ion , th ere sh ould be
• No oral liqu ids for 2 h ou rs p rior to p rocedure in ch ildren < 2 years of
age—3 h ou rs if > 3 years.
• No m ilk or solid food for 8 h ou rs p rior to th e procedu re.
Du ring th e p rocedu re,
• Main tain con t in uou s oxygen sat u rat ion an d h eart rate m on itoring.
• Record vit al sign s an d blood p ressure ever y 15 m in u tes for con sciou s
sedat ion an d ever y 5 m in u tes for deep sedat ion .
• Record dr ug dose an d t im e adm in istered.
• Record state of con sciou sn ess an d resp on se to st im u lat ion .
As p recau t ion ar y m easures, en su re th at
• Nasal can n ula an d in t u bat ion t ray are available du ring th e
procedu re.
• Reversal agen t s are ready, prep ared in syringe (Narcan [Du Pon t
Ph arm a] 0.4 m g IV pu sh ever y 2 to 3 m in utes as n eeded, u m azen il
0.2 m g IV p u sh given over 30 secon ds, th en 0.3 m g IV push given
over 30 secon ds as n eeded, m axim u m total d ose 3 m g).
• Suct ion ing apparat u s an d can ister are available.
• Nursing sta is in th e room du ring th e procedu re to assist .
• Dr ug com bin at ion s th at in clu de am n est ic an d an algesic e ects are
u sed.
The drugs co m m o nly used are as fo llow s (Table 2.2):
• For ad u lts.
– Sh or t procedure: Versed (Ho m an LaRoch e) + fen tanyl.
– Moderate in ter val p rocedu re: Morph in e + At ivan (Biovail
Ph arm aceu t icals, In c.).
• For pediat ric pat ien ts.
– Ketam in e + Versed.
For all pat ien t s, st art w ith a subth erapeu t ic dose, th en rebolu s in sm all
in ter vals to t it rate sedat ive e ect .

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12 Anesthesia and Wound Closure

Anesthesia and Wound Closure 13

Sutures
A variet y of su t u re m aterials are available, an d, in gen eral, th ey can be
di eren t iated based on th e follow ing categories (Table 2.3):
•
•
•
•

Absorbable versus n on absorbable.
Braided versu s n on braided.
Ten sile st rength .
Half-life.

A variet y of n eedles are also available an d can gen erally be classi ed as
t aper or cut t ing.
• Taper/rou n d n eedle: Use in m u scle, car t ilage, an d m ucosa.
• Cut t ing n eedle: For skin .
– Use a h alf-circle cu t t ing n eedle for subcu tan eous t issue.
– Use a 3/8-circle cu t t ing n eedle for skin .

Suture Techniques (Fig. 2.1)
• Sim ple interrupte d: Gen eral t issu e ap proxim at ion .
• Co ntinuo us running o r running baseball: An e ect ive an d fast
con t in u ou s su t u re for long lacerat ion s.
• Ve rtical m attress: Most e ect ive st itch for ever t ing skin edges. Be
careful to n ot set ten sion too t igh t to preven t t issu e n ecrosis.
• Ho rizontal m attress: E ect ive in evert ing skin edges. Be carefu l to
n ot set ten sion too t igh t to p reven t t issu e n ecrosis.
• Running subcuticular: A buried derm al sut u re for closing skin in
clean w ou n d s w ith ou t jagged edges.
• Staples: Sim ple an d fast closu re com m on ly u sed in th e scalp or
dir t y w oun d s to be closed loosely to allow drain age. Staples sh ould
be rem oved in 5 days to avoid ep ith elializat ion an d a p oor cosm et ic
result .
• Adhesive skin tape: Used to reapp roxim ate sm all lacerat ion s w ith
ver y lit tle ten sion .
• Derm abo nd (Ethico n): Skin adh esive th at can be u sed for clean
lacerat ion s w ith ou t jagged edges. After th e w ou n d is adequ ately
prepared, reapp roxim ate skin edges w ith a nger an d apply th e rst
coat , let it dr y for 20 secon ds, an d th en ap ply a secon d coat .
• In con clu sion , th e ast ute p ract it ion er w ill rep air lacerat ion s an d
w ou n ds in th e follow ing order:

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14 Anesthesia and Wound Closure

Anesthesia and Wound Closure 15

1. An esth et ize th e pat ien t’s w ou n d.
2. Débride it m et iculou sly w ith rem oval of jagged edges,
devit alized t issue, an d any foreign bodies.
3. Properly irrigate th e w ou n d in prep arat ion for closu re.
4. Obtain h em ostasis.
5. Rep air th e w ou n d in layers w ith care to reapproxim ate th e
derm al an d epiderm al layers of th e skin to p rovide th e pat ien t
w ith th e best cosm et ic resu lt .

Fig. 2.1

Suture techniques.

3

Pressure Sores

Th e t reat m en t of pressu re sores can be a long an d di cu lt ch allenge.
Pressu re sores are frequ en tly a secon dar y sequ ela to th e sed en t ar y
pat ien t w ith a m ore com plicated p rim ar y issu e. Com m on ly, pat ien ts
w ith pressure sores presen t w ith m ult iple com orbidit ies. It is essen t ial
to keep in m in d th at th e likely source of fever an d in fect ion is often t im es
n ot th e sore it self, sin ce m ost sores are open to drain . Each case w arran ts
a com plete evaluat ion by th e exam in er to rule ou t th e pressure sore as
th e likely cau se of an in fect ion .

Pressure Sore Staging System (Fig. 3.1)
• Stage 1: In t act skin w ith n on blan ch able er yth em a.
• Stage 2: Su p er cial u lcer involving p ar t ial t h ickn ess of t h e
ep id er m is an d d er m is; u su ally p resen t s as an abrasion , blister, or
ver y sh allow u lcer.

Fig. 3.1

16

Pressure sore staging system .

Pressure Sores 17

• Stage 3: Fu ll-th ickn ess skin loss dow n to th e su bcu tan eous t issue,
w h ich does n ot exten d beyon d u n derlying fascia.
• Stage 4: Full-thickness skin loss dow n th rough subcutan eous tissue
w ith involvem ent of m uscle, bone, tendon, ligam en t, or joint capsule.

Evaluation
Position the patient in a w ell-lit area to facilitate visualization of th e
ulcer. Gen tly p robe th e w ou n d an d assess for u id collect ion or pu rulen t
drain age. If pu s is p resen t , in cision an d drain age (I&D) sh ou ld be p erform ed an d th e w ou n d irrigated cop iou sly an d packed w et to dr y (see
below ). Obt ain a cu lt u re an d sam ples of th e pu ru len t m aterial. Necrot ic
soft t issu e is com m on . If it is devoid of pu ru len t d rain age, it is un likely
to be t h e sou rce of sep sis. Cop iou s drain age m ay be in dicat ive of a m u ch
larger w ou n d ben eath th e skin .
Subcu tan eous fat an d m uscle are m ore pron e to isch em ia th an skin .
Th erefore, in t act skin (possibly w ith sm all esch ar) m ay h arbor a large
area of n ecrot ic t issu e below, m aking th e w ou n d u n st ageable. Often , an
esch ar at or above th e adjacen t skin layer is in dicat ive of par t ial skin
th ickn ess loss. An esch ar th at is depressed m ay rep resen t fu ll-th ickn ess
skin loss.
Larger sores m ay w arran t radiograph ic evaluat ion to assess th e
exten t of soft t issue involvem en t an d possible bony involvem en t . CT
scan or MRI w ill provide m ore in form at ion versu s t radit ion al X-ray. An
MRI sh ou ld be p erform ed to ru le ou t osteom yelit is if bon e cu lt u res are
n ot available. Ch eck rout in e st udies—CBC, blood cult ures, CXR, blood
sugar, albu m in an d p realbu m in , ESR, CRP, an d u rin alysis. Rule out oth er
possible system ic causes of fever—pn eu m on ia, cen t ral lin es, an d u rin ar y
t ract in fect ion s. Ch eck for in con t in en ce.

Treatment
General Treatment for All Ulcers
• Alleviat ion of pressu re—place pat ien t on an air- uid m at t ress; u se
pillow s, egg car ton s, don u ts.
• Avoidan ce of sh earing forces.
• Frequ en t t u rn ing of th e pat ien t , h ou rly if p ossible.
• Clean ing or d iver t ing aw ay in con t in en ce—use of Foley an d
suprap u bic cath eter, rectal t u be, or colostom y.
• Ma xim izing n ut rit ion (albu m in > 3.0, p realbu m in > 18).

18 Pressure Sores

For Staged Ulcers
• Stage 1: Use m oist u rizers to p reven t dr yn ess.
• Stage 2: No débridem en t is n ecessar y; u se occlusive d ressings such
as polyu reth an e lm (Du oderm [Convatec In c.]) or hydrocolloids.
• Stages 3 and 4: Sh arp débridem en t is often n ecessar y w ith th e
addition of pulse lavage irrigat ion . Woun ds are p acked w et to
dr y w ith Kerlix (Ken dall Co.). Con sider bon e biopsy to assess for
osteom yelit is an d to obtain bon e cult u res to gu ide an tibiotic th erapy.
Th e in it ial t reat m en t an d m an agem en t of a pressu re sore sh ou ld
include t r ying to alleviate th e pressu re th at in it ially cau sed th e w ou n d.
Even a clean w ou n d w ill h ave t rou ble h ealing if th e in cit ing even t is st ill
presen t . Proper débridem en t an d w ash out is param oun t . A m in im al to
m oderate am ou n t of n ecrot ic t issu e can often be débrided at bedside
w ith local an esth esia, scissors, an d a scalpel. Larger areas sh ou ld be don e
in th e operat ing room becau se of pain an d th e poten t ial for un con t rolled
bleeding. Sh arp débridem en t sh ou ld be perform ed d ow n to h ealthy
vitalized t issu e th at bleeds. Properly an esth et izing th e p at ien t w ill h elp
w ith p ain con t rol an d h em ost asis. Refer to Ch apter 2 for a list of local
an esth et ics to u se.
Wet to dr y d ressings can be don e w ith n orm al salin e, 0.25% Dakin’s
solut ion , 0.25% acet ic acid, an d gau ze. Kerlix gauze is com m on ly u sed
becau se of th e large su rface area it can cover. Kerlix gau ze is soaked in
on e of th e p referred solut ion s an d th en squeezed dr y. Th e m oist gauze
is th en in ser ted an d p acked directly in to th e w ou n d to cover th e en t ire
surface of th e w oun d. Do n ot place m oist Kerlix directly on th e skin ,
sin ce th is can lead to skin m acerat ion . Th e dressing sh ould be ch anged
t w o to th ree t im es p er day dep en ding on h ow dirt y th e w oun d is. Wet to
dr y dressings keep th e w oun d m oist an d allow for m ech an ical débridem en t of devit alized t issu e on ce th e gau ze dries, h en ce th e n am e “w et to
dr y.” Dakin’s 0.25% or acet ic acid 0.25% solu t ion sh ou ld be u sed in th e
infected pu r ulen t w ou n d; h ow ever, it sh ould be discon t in ued on ce th e
w ou n d is clean , sin ce both solu t ion s can in h ibit t issu e grow th an d h ealing. Most h osp it als h ave a w ou n d care team t h at can assist w ith bedside
pu lse lavage an d a sm all am oun t of sh arp débridem en t by th e w oun d
ostom y n u rse. Con su lt th e w ou n d care team for assist an ce w ith dressing
ch anges, bedside pulse lavage, an d m in or débridem en ts. Duoderm m ay
be p laced on eith er side of th e w ou n d, th ereby avoiding frequ en t t ape
con tact directly w ith th e skin .
En zym at ic débridem en t is a com m on adju n ct to th e m an agem en t of
pressu re ulcers. Agen t s such as San t yl (Sm ith an d Neph ew ) are frequen tly
ap plied to th e w ou n d to p rovide con st an t p roteolyt ic débridem en t .

Pressure Sores 19

Alth ough frequ en tly u sed, th ey are by n o m ean s a su bst it u te for sh arp
m ech an ical débridem en t of n ecrot ic t issu e. Th ese agen ts h ave low m orbidit y an d assist in clean ing u p th e sm all am ou n t s of n ecrot ic t issu e th at
are often h ard to com p letely rem ove du ring bedside débrid em en ts.
If th e pat ien t is seen in th e em ergen cy room an d th ere is n o cellu lit is, n o elevat ion in w h ite blood cell cou n t , an d n o pu ru len t drain age,
th en th e w ou n d can be débrided as n ecessar y an d th e pat ien t can be
seen as an ou t p at ien t . In th ese cases, in st r u ct th e fam ily on (1) dressing
ch anges ever y 8 h ou rs, (2) th e im por tan ce of keeping th e w oun d clean ,
an d (3) th e n eed for frequ en t t u rn ing of th e pat ien t . If th e p at ien t presen t s w ith cellulit is an d purulen t drain age of th e w oun d, th en adm ission
to th e h osp it al sh ou ld be con sidered, especially if th e p at ien t h as oth er
com orbidit ies.
Silvaden e (San o -Aven t is Ph arm aceu t icals), Mafen ide Acetate
Cream , or Bet adin e (Pu rdue Products LP) can be used in selected cases
of w oun ds w ith super cial esch ars. Th ese are usu ally sm all sores th at
involve on ly th e derm is. Th ese an t im icrobial agen t s can h elp decrease
th e ch an ce of an in fect ion w h ile th e w ou n d h eals by secon dar y in ten t ion . Cu lt u re sw abs are of lit tle u se becau se all w ou n ds are colon ized,
even in th e clean gran u lat ing w ou n d. A qu an t it at ive t issu e biopsy can be
obtain ed to evaluate t issue bacterial coun t s (> 10 5 p er gram of t issu e),
an d bon e biop sy to r ule ou t related osteom yelit is.

4

Bite Wounds

Bite w ou n ds from an im als, in sect s, an d h u m an s are com m on ly presen t
in th e em ergen cy set t ing. More severe an d violen t bites can be associated w ith com p lex com posite t issu e d efects w ith devitalized t issue.
General m anagem ent includes:
1. In lt rate local an esth esia to an esth et ize th e w oun d to allow
th orough evalu at ion an d d ébridem en t .
2. Rem oval of foreign bodies (teeth ) an d débridem en t of devitalized
t issu e.
3. Copiou s irrigat ion w ith NS.
4. Determ in e if tetan us or rabies prop hylaxis is in d icated.
5. Repair of w oun d/lacerat ion —con sider loose closu re or leaving open
if in fected or con tam in ated.
6. Postclosu re an t ibiot ics an d m on itoring.

Human Bites
Hu m an m ou th s con tain som e of th e m ost con cen t rated an d varied bacteria. Organ ism s in clude Eikenella, Staphylococcus, viridan s st reptococci,
an d Bacteroides. Th e gen eral prin ciples of con t am in ated w ou n d m an agem en t , as m en t ion ed above, app ly to all h u m an bite w ou n ds. In th e
acute bite, th e w ou n d m u st be assessed fu lly an d irrigated copiously. Th e
pat ien t sh ou ld be p laced on ap propriate p rop hylact ic an t ibiot ics an d follow ed closely for any sign s of in fect ion .
Th e in it ial inju r y often ap pears m in or to th e pat ien t; th u s n o care
is sough t u n t il an in fect ion develops. It is im p ort an t to fu lly assess th e
pat ien t in th e u rgen t care set t ing an d t riage for p ossible h ospit al adm ission , IV an t ibiot ics, an d operat ive m an agem en t . Bite inju ries requ ire
carefu l evalu at ion for a deep in fect ion becau se of th e relat ively ben ign
presen tat ion of th eir ap pearan ce. At t im es, du e to th e close proxim it y of
th e skin an d u n derlying st ru ct u res, n er ve an d ten don inju ries m ay also
be presen t . Also, due to th e in h eren t depth of pen et rat ion by th e teeth ,
m icroorgan ism s easily seed th e depth of w ou n ds, allow ing rapid dissem in at ion along th e deep p lan es of th e fascia an d su bcu tan eou s t issu e.
Th erefore, r u le ou t a deep inju r y even w h en th e presen t at ion is a m in or
w oun d su ch as an abrasion .
20

Bite Wounds 21

Assessment and Treatment
1. Evaluate w ou n d for depth , foreign body, drain age, an d cellu lit is.
2. Assess for crepit u s (su bcu tan eou s em physem a), w h ich w ou ld
in d icate gas-form ing organ ism s along th e deep p lan es.
3. Débride devit alized t issu e an d copiou sly irrigate.
4. Loose closu re versus p ack w ou n d—facial bites sh ou ld be closed for
th e best cosm et ic resu lts.
5. Treat w ith an t ibiot ics.

Closed-Fist Injury (Fight Bite)
W ith closed- st inju ries, th e force of th e blow to t h e m ou th w ill often
pen et rate th e skin over th e m et acarpop h alangeal join t to lacerate or
in fect th e exten sor ten don an d con tam in ate th e u n derlying join t , su ch
as t h e m et acarpop h alangeal join t , w it h bacteria from th e m ou th . W h en
th e h an d is placed back in to a n eu t ral p osit ion , th e bacteria can be displaced, resu lt ing in m ore proxim al con t am in at ion . Figh t bite w oun ds n ot
on ly involve soft t issues but also can in fect join t s an d ten don s. Aggressive in cision an d drain age, irrigat ion , an d débridem en t in th e operat ing
room sh ould be con sidered for grossly con t am in ated w oun ds an d th ose
th at presen t late.
1. Evaluate w ou n d for depth , foreign body, drain age, an d cellu lit is.
2. Assess for crepit u s (su bcu tan eou s em physem a), w h ich w ou ld
in d icate gas-form ing organ ism s along th e deep p lan es.
3. Evaluate th e in tegrit y of th e exten sor an d exor ten don s ( exor
ten osyn ovit is).
4. Assess for loss of join t h eigh t , w h ich w ou ld in dicate m etacarpal
h ead fract ure.
5. Obt ain h an d series (r u le ou t m etacarpal h ead fract ure,
osteom yelit is, an d den tal foreign body).
6. Débride devit alized t issu e an d copiou sly irrigate.
7. Close th e w ou n d loosely or leave th e w ou n d op en an d p erform
daily dressing ch anges w ith gau ze.
8. Treat w ith an t ibiot ics.
Se e Ch apt e rs 1 4 an d 1 6 for m an age m e n t of fract u res of t h e m et acarp al h ead an d ext e n sor t e n d on inju r ies, resp e ct ively, associat e d w it h
gh t bit es.

22 Bite Wounds

Antibiotics
All pat ien ts seen in th e em ergen cy set t ing sh ould receive a single dose
of IV an t ibiot ics. IV an t ibiot ics sh ou ld be con t in ued in th ose w h o require
adm ission for m ore com plicated in fect ion s. Th ose w h o can be disch arged
h om e are released on th e appropriate oral regim en w ith close follow -u p
w ith in 1 w eek.
• First-line IV: Un asyn (P zer Ph arm aceut icals) 1.5 g IV ever y 6 hours or
clindam ycin 600 m g IV ever y 6 hours + Levo oxacin 500 m g IV daily.
• First-line oral: Augm en t in (Gla xoSm ith Klin e).
– Adult: 875/125 m g t w ice a day × 10 days.
– Pediat ric: 45 kg/day t w ice a day × 10 days.
– Alternat ives: Moxi oxacin 400 m g daily × 10 days or clin dam ycin
450 m g fou r t im es a day + Bact rim DS t w ice a day × 10 days.

Cat
Cat bites are d eep ly p en et rat in g w ou n d s t h at are h eavily con t am in ated ,
an d ap p roxim ately 80% of t h ese w ou n d s becom e in fected . Organ ism s
in clu d e Pasteurella m ultocida an d Staphylococcus sp ecies. Ir r igate h eavily, w ash daily, t reat w it h an t ibiot ics, an d see below for rabies vaccin at ion cr iter ia. Evalu ate for tet an u s p rop hyla xis. Do n ot close t h e w ou n d .

Antibiotics
• First-line oral: Augm en t in .
– Adult: 875/125 m g t w ice a day × 10 days.
– Pediat ric: 45 kg/day t w ice a day × 10 days.
– Alternat ives: Doxycyclin e 100 m g t w ice a day × 10 days or
cefu roxim e 0.5 g t w ice a day × 10 days.

Dog
Dog bites con st it ute 80 to 90% of all an im al bites. Organ ism s include P.
m ultocida, Bacteroides, viridan s st reptococci, Fusobacterium , an d Capnocytophaga. Massive force can often cause sign i can t avu lsion inju ries;
h ow ever, due to th e low er bacterial coun t , in fect ion is n ot seen as frequ en tly as in cat bites. Large avu lsion inju ries can be reapp roxim ated
loosely as long as th e w ou n d can be p acked an d allow ed to drain sh ould
an in fect ion en sue. Elevate an d t reat w ith an t ibiot ics. See below for
rabies vaccin at ion criteria. Evalu ate for tetan u s p rophylaxis.

Bite Wounds 23

Antibiotics
• First-line oral: Augm en t in .
– Adult: 875/125 m g t w ice a day × 10 days.
– Pediat ric: 45 kg/day t w ice a day × 10 days.
– Alternat ives: Un asyn 1.5 g IV ever y 6 h ou rs or clin dam ycin 450
m g four t im es a day + Bact rim DS t w ice a day × 10 days.

Rabies
Rabies is a viral infection of the central and peripheral nervous system
that causes en cephalitis w ith or w ithout paralysis. If left untreated, it has
close to 100% m ortalit y. In the United States, rabies is m ost com m on in
bats, raccoon s, skun ks, foxes, coyotes, ferrets, cats, and dogs. Bats are th e
m ost com m on w ild anim als to carr y rabies. Cats are the m ost com m on
dom estic anim als to carry rabies because of the high num ber of unvaccinated strays an d their contact w ith raccoons, bats, an d oth er w ild an im als.
Transm ission is through the m ucous m em branes and saliva through
breaks in the skin. The virus then replicates locally in the m uscle and eventually travels through peripheral nerves to the spinal cord, then to the brain.
Incubation tim es have ranged from as short as 5 days to as long as 7 years;
however, the average incubation tim e is approxim ately 1 to 3 m onths. Com m on signs and sym ptom s of rabies are detailed in the box below.

The most common signs and symptoms of rabies infection
Paresth esias at th e site of th e bite
Hyp ersalivat ion
Hydrop h obia
Altered m en tal stat us
An xiet y
Hyperact ivit y
Bizarre beh aviors
Hyper ten sion
Hyp er th erm ia
Hyper ven t ilat ion
Spasm s an d con t ract ion s of th e n eck m u scles
Ph ar yngeal an d respirator y m u scle paralysis
Seizures

24 Bite Wounds

Treatment
Th e w ou n d sh ou ld be copiou sly irrigated w ith n orm al salin e. Devit alized t issu e sh ou ld be adequ ately débrided, w ith all w oun ds left open to
h eal by secon dar y in ten t ion . Tetan us st at us sh ould be determ in ed an d
vaccin e adm in istered if in dicated (see Ch apter 1). A broad-spect r um
an t ibiot ic m ay be adm in istered for 10 days (Augm en t in 875/125 m g by
m outh t w ice a day).

Domestic Animals
If th e rabies st at u s of th e dom est ic an im al (e.g., cat , dog, ferret) is
un kn ow n , th e an im al sh ou ld be qu aran t in ed an d obser ved for 10 days;
prophyla xis can be p ost p on ed if su sp icion is relat ively low. If th e an im al
is rabid or if th e presen ce of rabies is h igh ly su spected, h u m an rabies
im m u n oglobu lin (RIG) an d h u m an diploid cell rabies vaccin e (HDCV)
sh ould be adm in istered.
• RIG: 20 IU/kg, 50% in to th e w ou n d an d 50% given IM.
• HDCV: Given on days 0, 3, 7, 14, an d 28.

Wild Animals
Regard all w ild an im als (e.g., bat s, foxes, coyotes, raccoon s, sku n ks) as
rabid. Test th e an im al if capt u red an d adm in ister RIG an d HDCV to all
pat ien ts as in dicated above.

Snake
Th e m ajorit y of sn akes are n onven om ou s; th erefore, sn akebite w ou n ds
w ill likely h eal w ith out exten sive in ter ven t ion . Ven om ous sn akebites,
h ow ever, can pose a severe th reat to th e local soft t issu es or cause
life-th reaten ing system ic react ion s. Th e fam ily Viperidae is th e largest
fam ily of ven om ous sn akes w orldw ide. Th e subfam ily Crotalin ae (pit
vipers) in clu des rat tlesn akes, cot ton m ou th s, an d copp erh eads; pit vip ers
are th e m ost com m on t yp e of ven om ou s sn ake in th e Un ited St ates. Th e
fam ily Elapidae is th e n ext largest fam ily of ven om ous sn akes. Coral
sn akes are com m on ly fou n d in th e sou th ern an d sou th w estern region s
of th e Un ited States, w h ile cobras, m am bas, an d kraits are n ot in digen ous to th e Un ited States, but are exot ic sn akes th at can be foun d in zoos
or are kept by private collectors.

Bite Wounds 25

Th e iden t i cat ion of th e sn ake’s species is im portan t in determ in ing if enven om at ion is expected. Com m on ly p at ien t s w ill presen t w ith
kn ow ledge of th e t ype of sn ake th at w as involved (see Table 4.1 for som e
t ypes of ven om ous sn akes). Altern at ively, th e di eren t iat ion bet w een a
ven om ous an d a n onven om ous sn akebite can be m ade using th e pat tern
of the bite or physical feat ures of th e sn ake if brough t for presen t at ion
(Fig. 4.1).

Evaluation
Obt ain th orough h istor y th at in clu d es
• Tim e of th e bite.
• Descript ion of th e sn ake.
Assess th e t im ing of even ts an d on set of sym ptom s. (Early an d
in ten se pain im p lies sign i can t enven om at ion .)
Determ in e h istor y of prior exp osu re to an t iven in or sn akebite.
Table 4.1

Venom ous snake species

Family

Geographic range

Common names

Viperidae

Africa, Europe,
Asia,
North and South
Am erica

Subfam ily Crotalinae
(pit vipers) includes
rat tlesnakes
(diam ondback, tim ber),
cot tonm ouths,
copperheads

Pit vipers
are the m ost
com m on t ype of
venom ous snake
found in the U.S.

Elapidae

North Am erica,
Europe,
Africa,
Asia,
Australia

Coral snakes,
cobras,
mam bas,
kraits

Coral snakes
are com m only
found in the
U.S. in the
southern and
southwestern
states

26 Bite Wounds

Fig. 4.1

Characteristics of (a) venomous versus (b) nonvenomous snakes and their bite patterns.

Assessm en t an d physical exam in at ion sh ould det ail th e follow ing:
1. Fang m arks.
2. Edem a.
3. Bu llae.
4. Er yth em a.
5. Necrosis.
6. Crepit us.
7. Petech iae.
8. Paresth esia.
9. Hem opt ysis.
10.Presence of com partm ent syndrom e if the bite occurs on an
extrem ity (Fig. 4.2).

Bite Wounds 27

Fig. 4.2 (a) Fang marks characteristic of a venom ous snakebite. (b) Signs of severe local
reaction and compartm ent syndrom e. (c,d) Forearm and hand fasciotomy required for the
treatm ent of compartm ent syndrom e secondary to the reaction from a venomous snakebite.

28 Bite Wounds

Treatment
1. Review th e ABCs an d evalu ate th e pat ien t for sign s of sh ock
(e.g., t achyp n ea, t achycardia, d r y pale skin , m en t al st at u s ch anges,
hypoten sion ).
2. Obtain baselin e laboratories (in clu ding PT, PTT, an d INR) an d CXR;
t ype an d crossm atch pat ien t for FFP an d PRBCs.
3. Rule ou t com par t m en t syn d rom e an d assess ever y 4 h ours for sign s
of com part m en t syn drom e (see Ch apter 19).
4. Tet an u s prophyla xis.
5. Prophylact ic an t ibiot ic u se is con t roversial; h ow ever,
som e recom m en dat ion s in clu de th e follow ing: Roceph in
(Roch e Ph arm aceu t icals) 1 g IV ever y 12 h ou rs or Tim en t in
(GlaxoSm ith Klin e) 3.1 g IV ever y 6 h ours.
6. Im m obilizat ion , n eu t ral p osit ion ing (splin t) of ext rem it y, an d
suppor t ive care. Su ct ion devices on th e bite can be e ect ive in th e
rst 15 to 30 m in u tes. Do n ot at tem pt in cision over th e bite, m outh
suct ion ing, tou rn iqu ets, or ice p acks.
7. Elevate the invo lve d extrem ity. Th is m ay requ ire th e aid of an
IV p ole, w ith w h ich th e ext rem it y is h u ng u sing a stockin et te.

Grading of Envenomation
1. Mild enven om at ion .
a. Local pain an d ed em a.
b. Sign s of system ic toxicit y are absen t .
c. Laborator y valu es are n orm al.
2. Moderate enven om at ion .
a. Local react ion —severe pain , edem a greater th an 12 in ch es
surrou n ding th e w ou n d.
b. Mild system ic toxicit y presen t , in clu d ing n au sea, vom it ing.
c. Abn orm al laborator y valu es—decreased h em atocrit or platelet
values.
3. Severe enven om at ion .
a. Severe local react ion an d gen eralized p etech iae, ecchym osis.
b. Severe system ic react ion —respirator y dist ress, air w ay edem a,
blood-t inged spu t u m , hyp oten sion , ren al dysfun ct ion .
c. Ch anges in coagulat ion p ro le—PT, APTT, an d DIC.
Antivenin is give n for m oderate and severe cases of snake envenom ation.
Serum sickness is possible w ith antivenins, w hich are m ade w ith horse or
sheep serum venom . A test dose is recom m ended; watch for an anaphylactic reaction. CroFab (BTG International Inc.) is a puri ed pit viper antivenin

Bite Wounds 29

that has few er hypersensitivit y reactions, so that serum sickness is less of
an issue. CroFab is the preferred antivenin for pit viper envenom ation.
An t iven in is given in am p u les. On e sh ou ld st ar t w ith 5 to 10 vials an d
con t in u e th erapy for u p to 24 h ours from th e in it ial bite. If th e pat ien t
respon ds (a decrease in both local an d system ic react ion ), th en a dosing
regim en of an t iven in can be w ean ed. If th e pat ien t respon ds par t ially,
plan to redose th e an t iven in . Pat ien t s sh ou ld be m on itored in an ICU
set t ing du ring adm in ist rat ion of an t iven in for sign s of allergic react ion .
Bites fro m co ral snakes (“red on yellow kills a fellow ”) are n ot t reated
w ith an t iven in in th e Un ited States due to lack of produ ct ion of speci c
coral sn ake an t iven in an d a h alt by th e FDA on th e product ion of Wyeth’s
Nor th Am erican coral sn ake an t iven in . Because a speci c an t iven in for
coral sn akes is n ot available, pat ien t s are curren tly t reated w ith m on itored sup por t ive care.

Spider
Th ere are over 20,000 species of spiders on Ear th . Dangerous species
often en coun tered in Nor th Am erica in clu de th e brow n recluse, th e
black w idow, th e h obo or aggressive h ou se spider, an d th e yellow sac
sp ider. Of th ese, on ly t h e brow n reclu se an d t h e black w idow h ave ever
been associated w ith sign i can t disease (Fig. 4.3).

Fig. 4.3 The black widow
and brown recluse spiders.

30 Bite Wounds

The Brow n Recluse Spider
Th e brow n reclu se sp ider h as six eyes an d a violin -sh ap ed p at tern on it s
th orax an d is fou n d alm ost exclu sively in t h e Midw estern an d sou th eastern st ates. Alt h ough th e ven om is m ore toxic th an t h at of th e rat tlesn ake,
m orbidit y is usu ally n ot as severe because of th e sm all am oun t of ven om
th at can act u ally be injected by th e creat u re. On e of th e sp eci c en zym es
in th e ven om cau ses dest ruct ion of skin , fat , an d blood vessels. Th is process even t u ally leads to soft t issue n ecrosis at th e site of th e bite.
Th e ven om also h as a profou n d e ect on th e im m u n e respon se, t riggering th e release of various in am m ator y cytokin es, h ist am in es, an d
in terleu kin s th at can th em selves cau se furth er injuries an d system ic
respon ses. Alth ough rare, th ese in clude h em olysis, th rom bocytop en ia,
coagulopathy, acu te ren al failu re, com a, or death .
On e sh ould carefully assess th e pat ien t for any of th e above sym p tom s, an d adm ission is w arran ted for anyon e exh ibit ing system ic toxicit y. Apply ice to decrease pain an d sw elling, an d elevate th e site of injur y
above th e h ear t . Wash th e area th orough ly w ith soap an d w ater, an d
in st ruct th e pat ien t to avoid any st ren u ou s act ivit y, w h ich can facilitate
th e sp read of th e ven om . Do n ot place h eat on t h e area; th is can accelerate t issu e dest ru ct ion . Do n ot at tem pt to su ct ion th e ven om ou t , an d th e
use of steroid cream s is n ot advised.
Brow n recluse sp ider bites are u su ally p ain less at rst , an d sym p tom s are slow to develop . Pain w ill u su ally p resen t aroun d 4 h ou rs after
th e in it ial bite, w it h th e bite w ou n d p resen t ing w ith a bu ll’s-eye ap pearan ce. Blistering is th en com m on ly seen 12 to 24 h ours later, w ith soft t issu e n ecrosis to follow. Early débridem en t is n ot in d icated, an d n ecrot ic
lesion s sh ou ld be kept clean an d carefully dressed u n t il spreading stops
an d th e area of n ecrosis is w ell de n ed. A w ide area of t issu e aroun d
th e n ecrot ic skin can th en be rem oved, w ith su bsequ en t skin graft ing
as n eeded.
1. Baselin e laboratories sh ou ld in clu de CBC, Ch em -7, PT, PTT, an d INR.
2. Th ere is n o an t iven in available; h ow ever, dapson e 100 m g by m outh
daily can be reser ved for peop le w ith severe system ic disease
(an em ia, DIC, acute ren al failu re).
3. Acetam in oph en or op iates for pain . Avoid asp irin , ibup rofen (Mot rin
[P zer Ph arm aceu t icals], Advil [Wyeth Ph arm aceu t icals]), an d
n ap roxen (Aleve [Bayer Con su m er Care]).
4. Diph en hydram in e 25 to 50 m g by m ou th ever y 6 h ours as n eeded.
5. An t ibiot ics sh ou ld be adm in istered if sign i can t soft t issue n ecrosis
en sues. Pat ien ts sh ou ld be w atch ed ver y closely, w ith follow -u p th e
n ext day if possible.

Bite Wounds 31

The Black Widow Spider
Black w idow spiders are n oct urn al an d are foun d in th e south ern states.
Th is spider h as a dist in ct ive red-colored h ourglass gu re on it s u n derbelly. It s in it ial bite is usu ally associated w ith local pain follow ed by
system ic react ion s th at can carr y m ortalit y as h igh as 5%(u su ally in ch ildren or th e elderly). Gen eralized sym ptom s usu ally in clude
•
•
•
•
•
•
•

Nausea, vom it ing.
Fain t n ess, dizzin ess.
Ch est pain .
Hyp oten sion .
Tachycardia.
Respirator y di cult ies.
Abdom in al pain m im icking gallbladd er disease or app en dicit is.

Th ere is m in im al t issue toxicit y, an d th e w ou n d sh ou ld be irrigated an d
cared for in th e usu al m an n er. Treat m en t for system ic sym ptom s is su p por t ive, an d an an t iven in is available for severe cases. It sh ou ld on ly be
used if th e pat ien t is u n stable.
Cold com p resses h ave been u sed to ease th e p ain at th e site, as w ell as
over-th e-cou n ter p ain m edicat ion s. Over-th e-cou n ter p ain m edicat ion s
(e.g., acet am in op h en , n ap roxen , ibu profen , Advil) can be u sed, as w ell
as Ben adr yl 25 to 50 m g by m ou th ever y 6 h ou rs for itch ing. In gen eral,
an t ibiot ic prophyla xis an d exten sive m edical follow -up is n ot n eed ed.

5

Burns and Frostbite

Evaluat ion an d m an agem en t of th e acutely burn ed pat ien t is a com m on
requ irem en t of th e plast ic su rgeon on call. Rapid assessm en t , st abilizat ion , an d t riage are essen t ial for decreasing m orbid it y an d m or t alit y
associated w ith burn injur y. Com m on ly, th e in it ial en cou n ter w ill be
as a con sultan t subsequ en t to th e evalu at ion perform ed by th e em ergen cy room person n el. It is im perat ive, h ow ever, to rem em ber to in it iate m easu res to stop th e bu rn ing p rocess an d p ract ice u n iversal safet y
precau t ion s to con fer in creased safet y for both th e pat ien t an d th e caregiver. Bu rn inju r y is often associated w ith t rau m a; th erefore, a com plete
assessm en t of oth er inju ries sh ould be perform ed. If a ch ild is bu rn ed an d
th e m ech an ism of inju r y does n ot t th e bu rn p at tern or if t h e pat ien t
w as bu rn ed u n der u n likely circu m st an ces or con dit ion s, con sider abu se.

Thermal Burns
Initial Assessment—Starting w ith the ABCs
Airw ay
• Establish a paten t air w ay an d begin oxygen at ion .
– Em ploy m an u al tech n iqu es—ch in lift , jaw th ru st .
▪ Ut ilize n asal t ru m p ets an d oral air w ays.
▪ Con sider creat ing a su rgical air w ay w h en th ere is upp er air w ay
obst ru ct ion (cricoidectom y, t rach eostom y).
• Assess for in h alat ion inju r y (Fig. 5.1).
– Determ in e w h eth er th e bu rn s occu rred w h ile th e pat ien t w as in
an en closed space.
– Sign s an d sym ptom s of in h alat ion inju r y.
▪ Soot deposits in th e oroph ar yn x.
▪ Carbon aceou s sp u t u m .
▪ Singed n asal h air.
▪ Facial edem a, tongu e edem a, h oarsen ess.
– Measure carboxyh em oglobin level.
▪ > 10% requ ires oxygen th erapy an d is h igh ly suggest ive of an
in h alat ion inju r y th at requ ires in t u bat ion .
32

Burns and Frostbite 33

Fig. 5.1 Signs of potential airway burns and inhalation injury.

• Gen eral criteria for in t u bat ion .
– Glasgow Com a Scale score < 8 (Table 5.1).
– In h alat ion injur y.
– Deep facial an d n eck bu rn s.
– Facial bu rn s w ith associated TBSA bu rn s > 40%.
– Large TBSA bu rn s—to allow adequ ate resuscit at ion .
– Oxygen at ion or ven t ilat ion com p rom ise.
▪ PaO2 < 60.
▪ PCO2 > 50.
▪ RR > 40.
Pat ien t s w h o presen t w ith burn s of th e h ead an d n eck an d in h alat ion
injur y m ay require early in t u bat ion to protect th e air w ay from late
edem a an d edem a th at occu rs du ring resu scit at ion .

34 Burns and Frostbite

Table 5.1

The Glasgow Com a Scale (score = E + M + V)

Eye opening (E)
Spontaneous

4

To speech

3

To pain

2

No response

1

Best m otor response (M)
Obeys verbal com m and

6

Localizes painful stim ulus

5

Flexion: withdrawal

4

Flexion: abnorm al

3

Extension

2

No response

1

Best verbal response (V)
Converses and oriented

5

Converses but disoriented

4

Inappropriate words

3

Incomprehensible sounds

2

No response

1

Breathing
• Provide h u m idi ed oxygen by face m ask.
• Expose th e ch est to assess ven t ilat ion , ch est excu rsion , degree of
ch est w all injur y, an d presen ce of circu m feren t ial burn s to th e
th orax.
• Con sider th oracic esch arotom y for deep inju r y to th e ch est w ith
associated ven t ilator y com prom ise.

Burns and Frostbite 35

Circulation
• Establish vascu lar access w ith large-bore, h igh - ow ven ou s
can n ulat ion . Avoid th e inju red area if possible.
• In it iate m on itoring: BP, p u lse, tem perat ure.
• Con sider invasive ar terial lin es for m on itoring an d frequen t
laborator y blood draw s.

Disability
• Gross assessm en t of n eurologic stat u s (m n em on ic tool = AVPU).
– Aler t .
– Respon ds to Vocal st im u li.
– Respon ds on ly to Pain fu l st im uli.
– Un resp on sive to all st im u li.
• Glasgow Com a Scale (Table 5.1).

Exposure
• Rem ove all cloth ing an d debris to assess for gross inju ries an d for
bu rn severit y.
• Preven t hypoth erm ia by in creasing th e room tem p erat ure, covering
th e p at ien t w ith clean w arm lin en s, an d in fu sing w arm IV u ids.

Burn Severity Assessment
For in it ial acu te resu scitat ion , th e follow ing in form at ion is n ecessar y:
• Heigh t , w eigh t , an d age of th e p at ien t .
• Depth of th e bu rn injur y.
– Un iversal bu rn w oun d classi cat ion (Fig. 5.2).
• Percen tage of th e total body su rface area bu rn ed th at is secon d or
th ird degree.
– Th e percen tage of total body su rface area (TBSA) can be est im ated
by th e “r u le of n in es” (Fig. 5.3).
– More accu rate calcu lat ion can be don e w ith bu rn ch ar ts
(Table 5.2), w h ich is im por t an t in th e pediat ric p opu lat ion .
– Gen erally, th e p at ien t’s h an d (p alm an d ngers) is est im ated as 1%
of th eir total body surface area.

36 Burns and Frostbite

Fig. 5.2

Burn wound classi cation.

Epidermal Burns, First Degree (Fig. 5.4)
•
•
•
•
•
•

Zon es of inju r y are con n ed to th e epiderm is.
Sim ilar to su n bu rn .
Non blan ch ing er yth em a.
Ver y pain ful.
Heals in 1 w eek.
No sign i can t scarring.

Partial-Thickness Burns, Super cial Second Degree
(Fig. 5.5)
• Con n ed to th e u pp er th ird of th e derm is.
• Th e edem a layer bet w een th e inju red layer an d n orm al derm is
causes blistering.
• Com m on ly, th ese are th e resu lt of brief h ot-liquid exposu re.
• Wou n ds are w et , p in k, an d blistering.
• Wou n ds h eal in 10 to 14 days w ith m in im al scarring.

Burns and Frostbite 37

Fig. 5.3

The rule of nines for adults and children.

Fig. 5.4

First-degree epidermal burn.

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38 Burns and Frostbite

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Burns and Frostbite 39

40 Burns and Frostbite

Fig. 5.5

Super cial second-degree burn with blistering and epiderm olysis.

Partial-Thickness Burns, Mid-dermal Second Degree
(Fig. 5.6)
• Result from longer h ot-liqu id exposu re, grease, an d ash am es.
• Wou n ds are red w ith m in im al exudates an d m oderately pain ful.
• Wou n ds h eal in 2 to 4 w eeks w ith m od erate scarring.

Partial-Thickness Burns, Deep Dermal Third Degree
(Fig. 5.7)
• Result from exp osu re to am es, grease, ch em icals, an d elect ricit y.
• Wou n ds are u su ally dr y, w h ite, an d m in im ally pain ful (due to
dam age to n er ve en dings).
• Gen erally, w ou n ds h eal in 3 to 8 w eeks w ith severe hyper t roph ic
scarring.
• Excision an d graft ing w ill accelerate closu re.

Burns and Frostbite 41

Fig. 5.6

Mid-derm al second-degree burn.

Full-Thickness Burns, Third Degree (Fig. 5.8)
• Resu lt from h igh en ergy an d p rolonged th erm al exp osure
(ch em icals, am es, elect ricit y, explosion s).
• Wou n ds are dr y an d w h ite, or exh ibit im m ediate esch ar form at ion .
• Wou n ds are pain less an d in sen sate.
• Th ese w ou n ds n eed débridem en t an d graft ing to prom ote h ealing.

Burn Patient Resuscitation
Pat ien t s w h o require in t raven ous cr ystalloid resu scitat ion an d possibly
uid balan ce m on itoring w ith a Foley cath eter p lacem en t are
• Adult s w ith secon d- an d th ird -d egree bu rn s > 20% TBSA.
• Ch ildren (< 14 years of age) w ith bu rn s > 15% TBSA.
• In fan t s (< 2 years of age) w ith bu rn s > 10% TBSA.

42 Burns and Frostbite

Fig. 5.7 (a) Deep dermal third-degree burn. (b) Deep derm al burn with areas of full-thickness involvem ent.

All oth er pat ien t s can be m an aged w ith oral hydrat ion .
Urin e ou t pu t is used to gauge th e success of u id resu scitat ion . If
th ere is any qu est ion as to th e p at ien t’s abilit y to pass u rin e, place a
Foley cath eter. Lact ated Ringer’s solu t ion sh ou ld be st ar ted as soon as
possible after th e t im e of th e bu rn . Th e volu m e of uid given in th e rst
24 h ours for adult vict im s is determ in ed by th e Parklan d form ula:
4 × w eigh t (kg) × % BSAB = volu m e of uid for 24 h ours
Th ese est im ates are based on secon d- an d th ird-degree bu rn inju ries
on ly.
Pediat ric p at ien t s h ave in creased u id requirem en ts secon dar y to
di eren ces in BSA-to-w eigh t rat io an d require larger volum es of urin e
for excret ion of w aste product s. Th e volum e required in th e rst 24 h ou rs
for th e burn ed pediat ric pat ien t is est im ated using th e Galveston form ula
(est ablish ed at th e Sh rin ers In st it ute for Bu rn ed Ch ildren , Galveston , TX):
u id volu m e for rst 24 h ou rs of resuscitat ion (m L) =
[2,000 m L × TBSA] + [5,000 m L × BSA (m 2 )]
Tot al Body Su rface Area (TBSA)
TBSA (m 2 ) = 0.007184 × (h eigh t in cm ) 0.725 × (w eigh t in kg) 0.425
Bu rn Su rface Area (BSA)
BSAB (m 2 ) = TBSA × % su rface area bu rn ed (u sing ru le of n in es or
calcu lated from bu rn % ch ar t)
The rate o f infusio n w h en u sing t h e Parklan d an d Galveston form u las
is as follow s:
• Half of th e determ in ed volu m e is given w ith in th e rst 8 h ou rs of
th e tim e of the burn.
• Th e rem ain ing volu m e is given du ring th e su cceed ing 16 h ou rs.

Burns and Frostbite 43

Fig. 5.8

Full-thickness burn injury.

Fluid requirem en ts beyond the rst 24 hours are determ ined based on
the patient’s w eight and evaporative losses, and adjusted according to the
patient’s response (i.e., urine output). Maintenance vo lum e of uid is
calculated in L/d as
• 100 m L/kg for rst 10 kg.
• 50 m L/kg for secon d 10 kg.
• 20 m L/kg for each addit ion al kg of body w eigh t .
In ad dit ion :
evaporated losses related to th e burn w ou n ds per day =
3,750 m L × BSAB (m 2 )
Th is volu m e is th en added to th e m ain ten an ce volu m e an d divided over
24 h ou rs.
Altern at ively, th e m ain ten an ce volu m e per day in th e postacu te
resu scitat ion period is calcu lated as
[1,500 m L × TBSA (m 2 )] + [3,750 m L × BSAB (m 2 )]
Ult im ately, th is calculat ion sh ou ld be adjusted to en sure adequate
en d-organ perfusion as m on itored by th e pat ien t’s u rin e out put , w h ich
sh ould be > 0.5 m L/kg/h for ad u lt s or 1 m L/kg/h for ch ildren . Bolu s
addit ion al IV u id to m ain tain adequ ate u rin e out pu t .

44 Burns and Frostbite

Escharotomy
Late t issu e edem a m ay lead to vascular com prom ise secon dar y to
decreased elast icit y of a bu rn scar. Th is is p ar t icu larly h azardou s in deep
burn s of th e ext rem it ies an d circum feren t ial burn s of th e ch est w all. An
esch arotom y is perform ed early for circu m feren t ial deep derm al an d
full-th ickn ess bu rn s to th e ext rem it ies an d ch est . Gen erally, esch arotom ies sh ould be perform ed by a surgeon or a physician experien ced in
th e procedu re to d ecrease m orbidit y.

Procedure (Fig. 5.9, Fig. 5.10)
• Use elect rocauter y or a scalpel to in cise th e bu rn ed skin .
• Exten d dow n th rough esch ar in to th e su bcu t an eou s fat .
• Cu t m idm edially or m idlaterally.

Fig. 5.9

Incision locations for escharotomy.

Burns and Frostbite 45

Fig. 5.10

Lateral and dorsal escharotomy of the upper extrem it y.

• Exten d th e in cision th e length of th e con st rict ing burn esch ar an d
across involved join ts.
• Avoid m ajor vessels, n er ves, ten d on s, an d p ressu re su rfaces.

Associated Conditions
Inhalation Injury
Th e leading cause of death in res is sm oke in h alat ion , n ot burn s. In h alat ion inju r y is presen t in on e-th ird of bu rn p at ien t s an d dou bles th e
m or t alit y rate from bu rn s.

Signs and Symptoms of Inhalation Injury
•
•
•
•
•
•

An atom ical distort ion of th e face an d n eck edem a.
In abilit y of th e p at ien t to clear secret ion s.
Altered m en t al st at us.
Decreased oxygen at ion .
In creased carboxyh em oglobin .
Lact ic acidosis.

Management of Inhalation Injury
• Evaluate pat ien t for in t ubat ion .
• Perform a beropt ic lar yngoscopy an d bron ch oscopy for diagn osis
an d soot/secret ion rem oval.
• 100% oxygen su pp lem en tat ion .
• Assess for carbon m on oxide poison ing.
• Elevate ch est/h ead to 20 to 30 degrees at all t im es.

46 Burns and Frostbite

• Liberal use of bron ch odilators su ch as albu terol.
• Tran sfer pat ien t to a bu rn cen ter or crit ical care set t ing.
For advan ced m an agem en t of severely burn ed air w ay:
• In t ubate; apply p osit ive pressu re ven t ilat ion .
• Posit ive en d-exp irator y pressu re (PEEP); m ain tain paten cy of
sm aller air w ays.
• Give th e p at ien t N-acet ylcystein e.
• Adm in ister n ebulized h eparin .
• Tran sfer pat ien t to a bu rn cen ter or crit ical care set t ing.

Carbon Monoxide Toxicity
Carbon m on oxide toxicit y is on e of th e leading cau ses of death associated w ith res an d is p rodu ced in th e p rocess of O2 com bust ion . Carbon
m on oxide preferen t ially bin ds to h em oglobin in place of oxygen an d
form s carboxyh em oglobin (COHb), w h ich sh ifts th e oxyh em oglobin dissociat ion cu r ve to th e left , redu cing oxygen deliver y. Sign s an d sym p tom s of carbon m on oxide poison ing are ou tlin ed in Table 5.3.

Management of Carbon Monoxide Toxicity
• Adm in ister h igh - ow oxygen by m ask (FiO2 100%) u n t il
carboxyh em oglobin is < 10%.
• For obt u n ded pat ien t s.
– In t u bate.
– 90 to 100% oxygen via p osit ive pressu re ven t ilat ion .
If th e pat ien t is n ot respon ding to 100% oxygen:
• Con sider advan ced m odes of ven t ilat ing.
– Volu m e Di u sive Respirator (VDR; Percu ssion aire), h igh
frequ en cy percu ssive ven t ilat ion
– Bi-level inverse rat io ven t ilat ion (IRV).
▪ Hyperbaric th erapy.

Burns and Frostbite 47

Table 5.3

Symptom s of carbon m onoxide poisoning

COHb (%)

Symptoms

0–10

Norm al value

10–20

Headache, confusion

20–40

Disorientation, fatigue, nausea, visual changes

40–60

Hallucination, com bativeness, com a, shock state

> 60

Mortalit y > 50%

Burn Patient Triage
On ce th e burn ed p at ien t is stabilized, th e app ropriate facilit y to care for
th e p at ien t is determ in ed. Triage of t h e bu rn pat ien t in clu des ou t p at ien t
m an agem en t , inpat ien t m an agem en t , m an agem en t by a t raum a ser vice,
or referral to a specialized burn cen ter. Th e criteria for referral to a burn
cen ter are ou tlin ed in Table 5.4.
Th e criteria for th e m an agem en t of burn vict im s as outpatients
in clu de th e follow ing:
• Burn s are < 10% par t ial-th ickn ess bu rn s w ith ou t in h alat ion inju r y.
• Pat ien t s are resp on sive to oral an algesics.
• Vict im s are com p lian t p at ien t s w h o w ill care for th eir w oun ds an d
presen t for follow -u p evalu at ion w ith in 3 to 5 days.
• Th ere is n o im m ediate or delayed risk to sp ecialized areas (i.e.,
circu m feren t ial bu rn s).
All oth er bu rn vict im s requ ire h osp it al adm ission for m ore exten sive
t reat m en t or m on itoring. At t im es, pat ien ts w ith m in or bu rn s m u st be
adm it ted for p ain con t rol or person al safet y/cau t ion , as in th e case of
abuse or pat ien ts w ith m u lt ip le preexist ing com orbidit ies or t rau m a.

48 Burns and Frostbite

Table 5.4

Burn Center Referral Criteria

A burn center may treat adults, children, or both. Burn injuries that should be
referred to a burn center include the following:
• Partial-thickness burns of greater than 10 percent of the total body
surface area.
• Burns that involve the face, hands, feet, genitalia, perineum , or m ajor joints.
• Third-degree burns in any age group.
• Electrical burns, including lightning injury.
• Chem ical burns.
• Inhalation injury.
• Burn injury in patients with preexisting m edical disorders that could
complicate managem ent, prolong recovery, or a ect m ortalit y.
• Burns and concom itant trauma (such as fractures) when the burn injury
poses the greatest risk of morbidit y or m ortalit y. If the trauma poses the
greater im m ediate risk, the patient’s condition m ay be stabilized initially in
a trauma center before transfer to a burn center. Physician judgm ent will
be necessary in such situations and should be in concert with the regional
medical control plan and triage protocols.
• Burns in children; children with burns should be transferred to a burn center
veri ed to treat children. In the absence of a regional pediatric burn center,
an adult burn center m ay serve as a second option for the m anagement of
pediatric burns.
• Burn injury in patients who will require special social, emotional, or longterm rehabilitative intervention.
Source: From Com m it tee on Traum a: Am erican College of Surgeons.
Reproduced with permission.

Burn Wound Management
Th e p at ien t sh ou ld be prem ed icated w ith an algesics prior to w ou n d
t reat m en t to decrease discom for t an d in crease p at ien t cooperat ion .

General Principles
•
•
•
•
•

Clean se th e w ou n ds of p ar t icles an d débride devitalized t issue.
In it iate tetan us prophylaxis.
Daily or t w ice-daily w oun d clean sing an d dressing.
An t ibiot ics on ly for gross soft t issu e in fect ion .
Aggressive pain con t rol.

Use ch lorh exidin e, 0.5% silver n it rate com bin ed w ith ch lorh exidin e glu con ate, n orm al salin e, or soap an d w ater to clean se th e burn w oun d. To
preven t w oun d in fect ion an d deeper w oun d conversion , topical an t im i-

Burns and Frostbite 49

crobials are u sed u n t il epith elializat ion of t h e w ou n d is com p lete. Th e
topical an t im icrobials are p rovided via gau ze ap plicat ion s, oin t m en t s,
cream s, or solu t ion s; dressings are ch anged at least t w ice a day. Com m on ly used topical an t im icrobials are outlin ed in Table 5.5 an d an t im icrobial dressings in Table 5.6.

Outpatient Wound Dressings
Epidermal First-Degree Burns
• Heal spon tan eou sly w ith lit tle in ter ven t ion requ ired.
• Moist urize th e w oun d to alleviate p ain .

Partial-Thickness Burns, Super cial Second-Degree Burns
• Treat blisters.
– Min or blisters over a sm all su rface area require n o in ter ven t ion .
– Large, ten se, t u rbid, p ain fu l blisters.
▪ Using asept ic tech n iqu e, asp irate w ith a large-bore n eedle,
leaving ep iderm is as a biologic dressing.
▪ Débride epiderm is if w ou n ds are con tam in ated.
▪ Clean w ou n d th orough ly an d dress.
▫ An t ibiot ic im pregn ated pet roleum gau ze.
▫ Biobran e (UDL Laboratories, In c.) for clean scald bu rn s.
▫ Aquacel Ag (ConvaTec) for w ou n ds w ith excessive exu date.
• Ap ply soft bulky gau ze d ressing.
• Adm in ister an algesics as n eeded.
• Follow u p in 2 to 3 days. If th e p at ien t is free of pain an d w oun ds are
h ealing, th en in st r u ct th e p at ien t or caregiver on h ow to con t in u e
dressing ch anges at h om e.

Mid- to Deep Dermal Burns, Second- and Third-Degree
Burns
• Clean w oun ds th orough ly w ith ch lorh exidin e.
• Débride su per cial devitalized t issu e.
• Dress w ou n ds w ith an t im icrobial m aterial.
– Silvaden e.
– Su lfam ylon for bu rn s w ith esch ar form at ion .
– Act icoat (Sm ith & Neph ew ) an d Mepilex Ag (Möln lycke Health
Care) are great altern at ives to cream s th at o er a m ore organ ized
an d easier app licat ion w ith a greater an t im icrobial sp ect r um .
• Ap ply soft bulky gau ze d ressing.

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