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Emergency Wound Management

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Emergency Medicine Manual, 6th Edition > Section 4. Emergency Wound Management >

PUNCTURE WOUNDS
Puncture wounds may injure underlying structures, introduce a foreign body, and plant
inoculum for infection. Infection occurs in 6% to 11% of puncture wounds, with Staphylococcus
aureus predominating. Pseudomonas aeruginosa is the most frequent etiologic agent in postpuncture wound osteomyelitis, particularly when penetration occurs through the sole of an
athletic shoe. Post-puncture wound infections and failure of an infection to respond to
antibiotics suggests the presence of a retained foreign body. Organized evaluation and
management is necessary to minimize complications.

Clinical Features (See Chapter 12)

Wounds older than 6 hours with large and deep penetration and obvious visible contamination,
which occurred outdoors with penetration through footwear and involving the forefoot, carry
the highest risk of infectious complications. Patients with a history of diabetes mellitus (DM),
peripheral vascular disease (PVD), or immunosuppression are at increased risk of infection.
On physical examination, the likelihood of injury to structures beneath the skin must be
determined. Distal function of tendons, nerves, and vessels should be assessed carefully. The
site should be inspected for location, condition of the surrounding skin, and the presence of
foreign matter, debris, or devitalized tissue. Infection is suggested when there is evidence of
pain, swelling, erythema, warmth, fluctuance, decreased range of motion, or drainage from the
site.

Diagnosis and Differential

A high index of suspicion must be maintained for a retained foreign body. Multiple view, "soft
tissue," plain film radiographs should be obtained of all infected puncture wounds and of any
wound suspicious for a retained foreign body (see Chapter 17 for recommendations on the
diagnosis and management of retained foreign bodies).

Emergency Department Care and Disposition

Many aspects of the treatment of puncture wounds remain controversial.
Uncomplicated, clean punctures < 6 hrs after injury:
Require only low-pressure irrigation and tetanus prophylaxis, as indicated.
Soaking has no proven benefit.
Healthy patients do not appear to require prophylactic antibiotics.
Prophylactic antibiotics:
"May" benefit patients with PVD, DM and immunosuppression.
Plantar puncture wounds, especially those in high-risk patients, located in the forefoot, or
through athletic shoes should be treated with prophylactic antibiotics.
Fluoroquinolones (such as ciprofloxacin 500 mg bid) are broad-spectrum antibiotics that
rapidly achieve high blood levels after an oral dose and are acceptable alternatives to parenteral
administration of a cephalosporin and aminoglycoside.
In general, prophylactic antibiotics should be continued for 57 days.

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In children: ciprofloxacin is not recommended for routine use. Cephalexin 2550 mg/kg/d
divided 4 times up to 500 mg can be used with close follow-up.
Wounds infected at presentation:
Need to be differentiated into cellulitis, abscess, deeper spreading soft tissue infections, and
bone or cartilage involvement.
Plain radiographs are indicated to detect the possibility of radiopaque foreign body, soft tissue
gas, or osteomyelitis.
Cellulitis:
Usually is localized without significant drainage, developing within 14 d.
There is no need for routine cultures.
Antimicrobial coverage should be directed at gram-positive organisms, especially S aureus.
710 days of a first-generation cephalosporin is usually effective.
Abscess:
A local abscess may develop at the puncture site, especially if a foreign body remains.
Treatment includes incision, drainage, and careful exploration for a retained foreign body.
Recheck wound in 48 hrs.
Serious, deep, soft tissue infections require surgical exploration and debridement in the OR.
Osteomyelitis or septic arthritis:
Suspect in any patient who relapses or fails to improve after initial therapy.
Obtain radiographs, WBC count, erythrocyte sedimentation rate, and orthopedic consultation.
Definitive management frequently necessitates operative intervention for debridement.
Pending cultures, start antibiotics that cover Staphylococcus and Pseudomonas species. A
reasonable regimen is parenteral nafcillin 12 g IV q4 hrs and ceftazidime 12 g IV q8 hrs.
Doses and intervals vary in children.
Conditions for admission include:
wound infection in patients with DM, PVD, or other immunocompromised states
wounds with progressive cellulitis and lymphangitic spread
osteomyelitis
septic arthritis
deep foreign bodies necessitating operative removal.
Tetanus prophylaxis should be provided according to guidelines (see Chapter 19).
Outpatients should avoid weight bearing, elevate and soak the wound in warm water, and have
follow-up within 48 hrs.

NEEDLE-STICK INJURIES
Needle-stick injuries carry the risk of bacterial infection in addition to the risk of infection with
hepatitis and human immunodeficiency virus (HIV). Each hospital should have a predesigned
protocol developed by infectious disease specialists for the expeditious evaluation, testing, and
treatment of needle-stick injuries, because recommendations in this area are complex and
changing.

HIGH-PRESSURE-INJECTION INJURIES
High-pressure-injection injuries may present as puncture wounds, usually to the hand or foot.
High-pressure-injection equipment is designed to force liquids (usually paint or oil) through a
small nozzle under high pressure. These injuries are severe owing to intense inflammation
incited by the injected liquid spreading along fascial planes. Patients have pain and minimal
swelling. Despite an innocuous appearance, serious damage can develop. Pain control should
be achieved with parenteral analgesics; digital blocks are contraindicated to avoid increases in
tissue pressure with resultant further compromise in perfusion. An appropriate hand specialist
should be consulted immediately, and early surgical debridement should be implemented for an
optimal outcome.

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HUMAN BITES
Human bites produce a crushing or tearing of tissue, with potential for injury to underlying
structures and inoculation of tissues with normal human oral flora. Human bites are most often
reported on the hands and upper extremities. Infection is the major serious sequelae.

Clinical Features (See Chapter 12)

Of particular concern is the clenched fist injury (CFI), which occurs at the metacarpophalangeal
(MCP) region as the fist strikes the mouth and teeth of another individual. These hand injuries
are at increased risk for serious infection, and any questionable injury in the vicinity of the MCP
joint should be considered a CFI until proven otherwise.
The physical examination should include assessment of the direct injury and a careful
evaluation of the underlying structures, including tendons, vessels, nerves, deep spaces, joints,
and bone. Local anesthesia usually is required to perform a careful wound exploration. In a
CFI, the wound must be examined through a full range of motion at the MCP joint to detect
extensor tendon involvement, which may have retracted proximally in the unclenched hand.
The examination also must assess a potential joint-space violation. Radiographs are
recommended, particularly of the hand, to delineate foreign bodies and fractures.
Human bites to the hand frequently are complicated by cellulitis, lymphangitis, abscess
formation, tenosynovitis, septic arthritis, and osteomyelitis. Infections from human bites are
polymicrobial, with staphylococcal and streptococcal species being common isolates in addition
to species-specific Eikenella corrodens.

Diagnosis and Differential

History and physical examination usually will indicate a straightforward diagnosis. There are
times, however, when a patient may try to conceal or deny the true etiology of a human bite,
and a high degree of suspicion is warranted, particularly when the wound is on the hand. It is
important to keep in mind that viral diseases also can be transmitted by human bites (eg,
herpes simplex, herpetic whitlow, and hepatitis B). The potential risk of acquiring HIV through
a human bite appears to be negligible due to low levels of HIV in saliva.

Emergency Department Care and Disposition

Copious wound irrigation with a normal saline solution and judicious limited debridement of
devitalized tissue are critical to initial management.
Human bites to the hand initially should be left open. Other sites can undergo primary closure
unless there is a high degree of suspicion for infection.
Prophylactic antibiotics:
Consider in all but the most trivial of human bites.
Amoxicillin/clavulanate 500875 mg PO bid (2545 mg/kg/day divided bid in children) is
the antibiotic of choice.
Uncomplicated, fresh CFI wounds:
Should be left open with an appropriate dressing.
The hand should be immobilized and elevated for 24 hrs, and prophylactic antibiotics should be
administered.
The patient should be reevaluated in 12 d.
If there is a laceration to the extensor tendon or joint capsule or radiographic findings, a hand
specialist should be consulted for possible exploration in the OR and admission for parenteral
antibiotics.
Wounds infected at presentation:

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Require systemic antibiotics after cultures are obtained.

Local cellulitis in healthy and reliable patients may be managed on an outpatient basis with
immobilization, antibiotics, and close follow-up.
Moderate to severe infections require admission for surgical consultation and parenteral
antibiotics.
Appropriate coverage includes ampicillin/sulbactam 3 g IV q6 hrs or cefoxitin 2.0 g IV q 8
hrs.
Penicillin-allergic patients may be treated with clindamycin plus ciprofloxacin.
Recommendations in children: see Chapter 70.
All patients should receive tetanus immunization according to guidelines.

DOG BITES
Clinical Features
Dog bites account for 80% to 90% of reported animal bites, with school-age children sustaining
the majority of reported bites. Infection occurs in approximately 5% of cases and is more
common in patients older than 50 years, those with hand wounds or deep puncture wounds,
and those who delay in seeking initial treatment over a 24-hour period. A thorough history and
examination as outlined in the section on human bites are required to assess the extent of the
wound and the likelihood of infection. Infections from dog bite wounds are often polymicrobial
and include aerobic and anaerobic bacteria.

Diagnosis and Differential

Radiographs are recommended if there is evidence of infection, suspicion of a foreign body,
bony involvement, or large dog intracranial penetration bites to the heads of small children.

Emergency Department Care and Disposition

All dog bite wounds require appropriate local wound care with copious irrigation and
debridement of devitalized tissue.
Closure:
Primary closure can be used in wounds to the scalp, face, torso, and extremities other than the
feet and hands.
Lacerations of the feet and hands should be left open initially.
Large, extensive lacerations, especially in small children, are best explored and repaired in the
OR.
Prophylactic antibiotics:
Puncture wounds, wounds to the hands and feet, and wounds in high-risk patients should
receive 35 d of prophylactic antibiotics with amoxicillin/clavulanate 500875 mg PO bid
(2545 mg/kg/day divided bid in children) or clindamycin plus ciprofloxacin.
Penicillin-allergic patients: clindamycin plus TMP-SMX.
Wounds obviously infected at presentation:
Need to be cultured and antibiotics initiated.
Reliable, low-risk patients with only local cellulitis and no involvement of underlying structures
can be managed as outpatients with close follow-up.
Significant wound infections:
Require admission and parenteral antibiotics.
Examples include infected wounds with evidence of:
lymphangitis
lymphadenitis
tenosynovitis

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septic arthritis
osteomyelitis
systemic signs
injury to underlying structures, such as tendons, joints, or bones.
Cultures should be obtained from deep structures, preferably during exploration in the OR.
Initial antibiotic therapy: begin with ampicillin/sulbactam 3 g IV q6 hrs or clindamycin plus
ciprofloxacin.
If the Gram stain reveals gram-negative bacilli, add a third- or fourth-generation cephalosporin
or aminoglycoside.
Tetanus prophylaxis should be provided according to standard guidelines.

CAT BITES
Cat bites account for 5% to 18% of reported animal bites, with the majority resulting in
puncture wounds on the arm, forearm, and hand. Up to 80% of cat bites become infected.

Clinical Features
Pasteurella multocida is the major pathogen, isolated in 53% to 80% of infected cat bite
wounds. Pasteurella causes a rapidly developing intense inflammatory response with prominent
symptoms of pain and swelling. It may cause serious bone and joint infections and bacteremia.
Many patients with septic arthritis due to P. multocida have altered host defenses due to
glucocorticoids or alcoholism.

Diagnosis and Differential

Radiographs are recommended if there is evidence of infection, suspicion of a foreign body, or
bony involvement.

Emergency Department Care and Disposition

Treatment is essentially the same as that for dog bite wounds.
All cat bite wounds require appropriate local wound care with copious irrigation and debridement of
devitalized tissue.
Closure:
Primary wound closure is usually indicated, except in puncture wounds and lacerations < 12
cm, because they cannot be adequately cleaned.
Delayed primary closure also can be used in cosmetically important areas.
Prophylactic antibiotics:
Administer to high-risk patients including those with punctures of the hand;
immunocompromised patients; and patients with arthritis or prosthetic joints.
The case can be made that all patients with cat bites should receive prophylactic antibiotics
because of the high risk of infection.
Amoxicillin/clavulanate 500875 mg PO bid (2545 mg/kg/d divided 2 times daily in
children), cefuroxime 500 mg PO bid (2030 mg/kg/d divided 2 times daily in children), or
doxycycline 100 mg PO bid in adults administered 35 days are appropriate.
For cat bites that develop infection, evaluation and treatment are similar to those for dog bite
infections. Penicillin is the drug of choice for P. multocida infections.
Tetanus prophylaxis should be provided according to standard guidelines.

RODENTS, LIVESTOCK, EXOTIC AND WILD ANIMALS

Rodent bites are typically trivial, rodents are not known to carry rabies, and these bites have a
low risk for infection. Livestock and large game animals can cause serious injury. There is also
a significant risk of infection and systemic illness caused by brucellosis, leptospirosis, and
tularemia. Aggressive wound care and broad-spectrum antibiotics are recommended.

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For further reading in Emergency Medicine: A Comprehensive Study Guide, 6th ed., see
Chapter 47, "Puncture Wounds and Mammalian Bites," by Robert A. Schwab and Robert D.
Powers.
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