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Subsections
Lacerations in the Field

Wilderness Medicine

Lacerations in the Field

Background

  1. Definition
    • Cut or wound usually from sharp objects in the environment
  2. Synopsis
    • History/Current Information/News
      • The Wilderness Medical Society published updated basic wound management practice guidelines in December 2014 1
      • Multicenter prospective cohort study on risks for infection of traumatic lacerations presenting to emergency departments in February 2014
        • Time to wound closure was not associated with infection rate 4
    • Lacerations are common in the wilderness
      • Categorization of wound into clean, dirty, or contaminated is essential, as management primarily depends on wound category
    • Most lacerations can be managed in the wilderness, though some require evacuation

Pathophysiology

  1. Mechanism
    • Cut or wound usually from sharp objects in the environment
  2. Etiology/Risk Factors
    • Sources
      • Falls
      • Environmental hazards
      • Animal attacks
    • Risk Factors
      • High infection environments, patient comorbidities
      • Aquatic environments have risk of infection
        • Unique and diverse bacterial pathogens
        • Injuries involving marine animals
      • Nutritional depletion, physical stress, high altitude
    • Risk factors for infection of traumatic lacerations presenting to an emergency department include the following 4
      • Diabetes
      • Lower extremity location
      • Contamination
        • > 6 hours old
        • Non-clean environment
        • Non-clean instrument
        • Gross contamination +/- foreign body
      • Laceration length > 5 cm
  3. Epidemiology
    • Incidence/Prevalence
      • Estimated 14.8% of national outdoor recreational injuries 5
      • Estimated 20.7% of all traumatic dermatologic conditions at Everest clinic 2
      • Soft tissue injuries accounted for 17% of injuries on National Outdoor Leadership trips between 2002-2005
        • Leads to an evacuation odds ratio of 2.73
    • Mortality/Morbidity
      • Cellulitis
      • Scarring
      • Limitation of function
      • Evacuation
      • Serious soft tissue infection

Diagnostics

  1. History/Symptoms
    • Past Medical History
      • Diabetes Mellitus
      • Immunosuppression
      • Malnutrition
      • Smoking history
    • Assess for
      • Mechanism of injury
      • Gross contamination, foreign body
      • High altitude
      • Continuous or repeat environmental exposure
      • Aquatic exposure
  2. Physical Exam/Signs (see also Wilderness Medicine: General Wound Management)
    • Full exam with good lighting
      • Consider local anesthesia
    • Cardiovascular
      • Evaluate distal perfusion
    • Skin/Extremities
      • Location, length
      • Evidence of infection, presence of foreign body
      • Joint involvement
    • Musculoskeletal/Nervous
      • Range of motion
      • Strength
      • Sensation
      • Tendon function
  3. Labs/Tests
    • Usually not available in the field/wilderness
  4. Imaging
    • Usually not available in the field/wilderness
  5. Differential Diagnosis

Treatment

  1. Initial/Prep/Goals
    • General principles for control of bleeding, local anesthesia, and wound preparation and cleaning
    • Prep and Clean algorithm:
      • Anesthesia in the field
        • Topical
          • Mix equal parts of 4% lidocaine, 0.1% epinephrine, and 0.5% tetracaine (LET)
            • Soak a 2 × 2 inch sterile gauze pad with this mixture
            • Place pad directly into and around wound for 7-10 min
            • Max dose of solution is 2-5 mL for adults
          • Use LET with caution on highly permeable tissue (i.e., mucous membranes)
            • *Note:
              • LET should be stored in a light-resistant container
              • LET is stable for 6 months when refrigerated and 4 weeks stored at room temperature
              • Discard if solution is discolored or cloudy
        • Local
          • Infiltrate wound with 1% lidocaine or 0.25% bupivacaine using a 25-gauge (or smaller) needle and syringe
            • Adult max dose of lidocaine: 4 mg/kg (28 mL of a 1% soln in a 70-kg [154-lb] adult)
          • Buffering lidocaine reduces pain during infiltration
            • Add 1 mL of sodium bicarbonate (1 mEq/mL soln) to 10 mL 1% lidocaine
            • Once buffered, shelf life greatly reduced - discard soln after 24 hrs
        • Alternative anesthetic strategies include the following:
          • Diphenhydramine: dilute 50-mg (1-mL) vial in syringe with 4 mL normal saline (NS) solution to produce a 1% soln
            • Perform local infiltration as usual
          • Use NS solution alone as the injected agent
            • May provide enough anesthesia to suture a small wound
          • Ice directly over wound to provide a short period of decreased pain sensation
      • "The greatest impact on wound cleanliness is gained from the volume of irrigant and simple mechanical debridement" 6
        • A clean field is adequate, though not sterile
        • Whatever method available to generate potable water for irrigation is sufficient (e.g., iodine tablets, mechanical filter, irradiation, boiling, etc.)
          • Hydrogen peroxide is injurious to deep tissues and should not be used as an irrigant
        • Pulsing irrigant at the wound rather than a single gush (dilution of wound contaminants far superior with small serial volumes)
          • A large (10-60-mL) syringe attached to a 18-20-gauge needle or catheter
          • About 5-10 psi if estimate possible (excessive pressures are not required)
          • Splash shield (easily be fashioned from a paper or plastic plate, or the base of a disposable water bottle or drinking cup)
          • Consider also putting on a pair of sunglasses or goggles to protect your eyes from the spray (especially if no splash shield possible)
          • Repeat irrigation until wound irrigated with ≥ 100 mL per cm of wound length
        • Improvised wound irrigation
          • Can be performed with a puncturable container to hold water
            • Plastic bottles (View image)
            • Sandwich or garbage bag and a safety pin or 18-gauge needle (View image)
              • Fill bag with irrigation solution and puncture bottom of bag with the safety pin
                • Enlarge hole if necessary, by puncturing it a second time
              • Hold bag just above wound and squeeze top firmly to begin irrigating
                • Pressure generated by this method is far less than by a syringe and catheter
        • Remove foreign debris (particularly organic)
          • Using gentle exploration, no extension of wound
          • Debride obvious non-vitalized tissue if easy to do so
        • If the wound edges are macerated, crushed, or necrotic, perform sharp debridement
          • Scalpels, scissors, sharp curettes, knives, and forceps to excise necrosis from a wound bed
      • In addition to a vigorous soap-and-water scrub, use benzalkonium chloride to cleanse wounds inflicted by animals suspected of being rabid
    • Categorize wound type:
      • Clean:
        • A simple wound in an area of the body with low bacterial count
        • Treated shortly after wound occurred (e.g., cut produced by a blade)
      • Dirty:
        • Located in an area with a high bacterial count (e.g., axilla, groin)
        • > 6 hrs old
        • Compression-induced stellate wounds (sustained when two bodies collide)
      • Contaminated:
        • Impregnated with organic soil (e.g., swamps, jungle), claylike soil, or fecal material
        • Already infected
        • Presenting > 8-12 hrs (or > 24 hrs if on the face)
        • Animal or human bites
      • Consider the wound to be the dirtier of two categories if there is a question
    • See Surgical/Procedural for definitive wound care overview
  2. Medical/Pharmaceutical
  3. Surgical/Procedural 6-7
    • Time to closure depends on location of wounds
      • Lacerations on extremity should ideally be closed within 8 hrs of injury
      • Lacerations on torso should be closed within 12 hrs
      • Wounds on face/scalp should be closed within 24 hrs
    • Determine whether to close per wound type
      • Clean and dirty wounds
        • Perform primary closure
        • Most clean wounds can be safely closed up to 6 hrs after injury; up to 10 hrs for face and scalp wounds
        • Simple, low tension: tissue adhesive glue, possibly with surgical tape
        • Complex and/or under tension: sutures or staples
        • Avoid staples in cosmetically important areas (e.g., the face)
      • Contaminated wounds
        • Pack open with wet to dry dressings to allow for closure by delayed primary closure (DPC) or secondary intention
        • Change the packing at least once a day
      • Wounds sustained in aquatic environment
        • Clean/irrigate well, leave open if in question, and observe closely
    • High-risk wounds that should not be primarily closed in the backcountry include
      • Animal or human bites to the hand, wrist, or foot, over a major joint or underlying fracture, or through the cheek
      • Deep puncture wounds
      • Deep wounds on hand or foot
      • Wounds with large amount of crushed or devitalized tissue
      • Wounds older than periods described earlier
      • Wounds occurring in immunocompromised treat as high-risk wounds
    • Low-risk wounds
      • Options for closing a wound in the backcountry:
        • Wound taping:
          • Wound closure tape strips are stronger, longer, stickier, and more porous than are butterfly bandages
        • Improvised wound tape:
          • If no tape is available, glue strips of cloth or nylon from your clothes, pack, or tent to the skin with a "superglue"
        • Improvised tape/suture closure:
          • Another method of wound closure using tape, which may be more appropriate for a longer wound
        • Hair-tying:
          • A scalp laceration; assumes the patient has enough hair
        • Gluing:
          • Dermabond (2-octyl cyanoacrylate) tissue glue provides strong tissue support and peels off in 5 days
        • Skin staples and sutures:
          • Large gaping cuts
          • Wounds that are under tension or that cross a joint
          • Wounds that are difficult to keep closed with tape
  4. Complications
    • If signs of infection develop:
      • Begin systemic oral antibiotic therapy
      • If it had been closed primarily, re-open laceration and drain if appropriate supplies available
      • Consider evacuation, especially if systemic symptoms or refractory to initial antibiotic therapy
  5. Prevention
    • Vaccines: Administer tetanus prophylaxis if indicated by history and exposure
    • Preventative measures
      • Provide a moist wound environment to support healing
        • Low-adherent dressings, semipermeable films (e.g., Tegaderm)
        • Topical antibiotic ointment
      • Apply a clean, protective wound bandage

Disposition

  1. Evacuation criteria 1
    • All complex wounds not closed primarily
    • Open fractures
    • Wounds with underlying tendon, joint, nerve, or vessel damage
    • Mammalian bites, or bites with any possibility of rabies inoculation
    • Any wound showing early signs of infection if appropriate early antibiotics not available
    • Progression of infection after administration of antibiotics
    • Presence of a large foreign body, especially if organic
    • Systemic toxicity (e.g., fever, alterations of consciousness, shock)
    • Concomitant hypothermia
    • Palpable gas in the soft tissues
    • Significant associated devitalized tissue
    • Tetanus-prone wounds requiring immunization

References

  1. Quinn RH, Wedmore I, Johnson E, et al. Wilderness Medical Society Practice Guidelines for Basic Wound Management in the Austere Environment: 2014 Update. Wilderness Environ Med. Sep 2014;25(3):295-310
  2. Némethy M, Pressman A, et al. Mt Everest Base Camp Medical Clinic "Everest ER": Epidemiology of Medical Events During the First 10 years of Operation. Wilderness Environ Med. Mar 2015;26(1):4-10
  3. McIntosh S, Leemon D, et al. Medical Incidents and Evacuations on Wilderness Expeditions. Wilderness Environ Med. Winter 2007;18(4):298-304
  4. Quinn J, Polevoi S, et al. Traumatic lacerations: what are the risks for infection and has the 'golden period' of laceration care disappeared? Emerg Med J. Feb 2014;31(2):96-100
  5. Flores AH, Haileyesus T, Greenspan AI. National Estimates of Outdoor Recreational Injuries Treated in Emergency Departments, United States, 2004-2005. Wilderness Environ Med. Summer 2008;19(2):91-98
  6. Jamshidi R. Wound Management. In: Auerbach PS, Cushing TA, Harris S; (eds). Auerbach's Wilderness Medicine, 7th ed., Elsevier, 2017; Chapter 21
  7. Lacerations, Abrasions, and Dressings. In: Auerbach PS, Constance BB, Freer L. Field Guide to Wilderness Medicine, 5th ed., Elsevier, 2019; Chapter 20

Contributor(s)

  1. O'Sullivan, Liam, MD
  2. Quinn, Robert, MD

Updated/Reviewed: December 2021