ED wound management: Identifying and reducing risk
By: James A. Pfaff, MD, FACEP, FAAEM, Interim Research Director and Staff Physician, San Antonio Uniformed Health Services Health Education Consortium; and Gregory P. Moore, MD, JD, Attending Physician Emergency Department, Kaiser Permanente Sacramento/Roseville, CA; Volunteer Clinical Faculty, Emergency Medicine Residency, University of California-Davis School of Medicine.
Editor’s note: The authors of this issue point out that 3-11% of malpractice dollars paid are disbursed for wound-related cases. Although wound infections may occur despite proper wound care, the detection of tendon or nerve injuries as well as joint violations requires a higher index of suspicion. This month’s review of wound management and its pitfalls serves the reader well by keeping the practitioner attentive to the potential problems of wound care. — Richard Pawl, MD, JD, FACEP
The information below are opinions of the authors and should not be construed as official or as reflecting views of the Department of Defense.
Scope of the Problem
Traumatic wounds are one of the most common reasons for emergency department (ED) visits; more than 12 million are seen in EDs throughout the United States.1 The majority of wounds are in men, and most are located on the head and neck or upper extremities.2 Upper extremity injuries usually involve the fingers. More than 50% of wounds are caused by blunt force; most others are caused by sharp objects (e.g., metal, glass, and wood).1 Animal and human bites are responsible for less than 10% of wounds requiring emergency care.3 Of all ED malpractice claims, 5-20% involve wound care; 3-11% of all malpractice dollars are paid for wound care-related cases.4 The most common reason for litigation involves failure to diagnose foreign bodies, wound infections, and failure to detect underlying injury to nerves or tendons, or a violation of a joint capsule.4
Most lacerations are closed primarily after irrigation, debridement, and exploration. Primary closure results in more rapid healing and reduced patient discomfort than does secondary closure.2 In general, the best way to prevent wound infections is with appropriate wound closure techniques after a thorough wound cleansing has been accomplished.5
However, wound infections still may occur, and the incidence of infection may be as high as 7% in extremity wounds.6 In that this article is not meant to describe comprehensive wound management, the reader should refer to standard resources for that information. This issue will address a number of high-risk concerns and appropriate wound management will be discussed.
Basic Wound Care
Anesthesia
After the appropriate general examination (e.g., neurological examination for head injuries and neurovascular examination for extremity injuries), anesthetizing the wound should be one of the first procedures on presentation to the ED. Adequate anesthesia facilitates comfortable wound inspection, irrigation, debridement, and if necessary, wound closure. Choices include the use of topical, regional, or local infiltration.
Topical anesthetics can be applied painlessly, may obviate the need for local infiltration, and can substantially relieve pain in patients who ultimately will need local infiltration. They particularly are advantageous for use in children, whose anxiety can sometimes be alleviated without the use of needles. Common formulations include lidocaine, epinephrine, and tetracaine (LET); tetracaine, adrenaline, and cocaine (TAC); as well as EMLA cream. Many of these preparations contain vasoconstrictors; therefore, their use should be avoided on digits, ears, the nose, and the penis. Care also should be taken with TAC in wounds near mucosal surfaces because systemic absorption of cocaine may result in respiratory depression or seizures.
Regional anesthesia has the advantage that it does not distort the patient’s anatomy and requires a smaller amount of anesthesia per surface area than local infiltration. It is especially useful for large surface areas and the lacerations of the hand and foot where local infiltration may be especially painful (e.g., the sole of the foot). However if the emergency physician is not experienced in regional anesthesia, inadvertent arterial injection can result in significant systemic consequences.7
Local anesthesia involves direct infiltration into the wound. Awareness of the amount of anesthetic used is critical; excess can cause a multitude of adverse effects, which are described in the discussion section below. This risk is greatest for large wounds when the amount of injected medication could approach the toxic doses of the anesthetic.
The classes of commonly used anesthetics are amides (e.g., lidocaine, bupivacaine, and mepivacaine) and esters (e.g., procaine, cocaine, tetracaine, and benzocaine). True allergies to these are rare; most problems are due to the metabolite para-aminobenzoic acid in the case of esters and the metabolite methylparaben in the amide anesthetics.8 In patients who have true allergies, alternative anesthetics include both benzyl alcohol and diphenhydramine. Diphenhydramine must be diluted to a 1% solution; although effective, it still can cause significant pain and tissue necrosis. Benzyl alcohol 0.9% with epinephrine is as effective as lidocaine and doesn’t cause the same problems as diphenhydramine.9
Knowing the indications, side effects, and toxicity is extremely important in the administration for any medications. The side effects most common with local anesthetics include: 1) central nervous system effects ranging from restlessness and paresthesias to seizures; 2) cardiovascular effects including vasodilatation, bradycardia, palpitations, and dysrhythmias; and 3) methemoglobinemia, particularly in children, and with accompanying cyanosis and lethargy.8 While not a true side effect, there also is the potential for vagal reactions with their use. It is imperative that the emergency physician adhere to the recommended per-kilogram and maximum doses listed for the anesthetic used. Some patients still may become toxic with smaller than the recommended dose.7
Procedural sedation may be necessary in children with certain wounds. The equipment and protocols should be in place to ensure the safety of the procedure: oxygen, suction, and airway equipment, resuscitation medications, monitoring equipment, reversal agents, and dedicated nursing personnel to monitor the patient. There are many medications available; their use depends upon the practitioner’s experience and comfort level. Ketamine is an excellent choice for sedation during wound repair in most children older than 3 months. It is easy to use (both IV and IM forms) and has an excellent safety profile.10 Short-acting benzodiazepines (e.g., fentanyl) often are used in combination to provide pain relief. This combination is very effective but also can increase the risk of respiratory depression. Self-administered nitrous oxide is effective for some procedures but requires a scavenger system and a cooperative patient. Propofol and etomidate also have been used with success.
Case #1. DS, as Trustee for Next of Kin of DS, Decedent v. Hospital.11
"DS" sustained a left thumb injury and was diagnosed with an ulnar collateral ligament rupture. It was decided to use an axillary block for anesthesia. Upon injection, his heart rate increased to 120 bpm, and he stated he felt a rush to his heart. After injection, he said he didn’t feel right and began to seize. Emergency CPR was started three minutes later. After aggressive and prolonged resuscitation, the patient was pronounced dead. Autopsy revealed probable bupivacaine toxicity. Plaintiff claimed that there was inadvertent injection directly into an artery. The case was settled in mediation for $475,000.
Wound Preparation
Wound management principles are the same whether it is a relatively clean incised wound or a grossly contaminated avulsion injury. The wound may be inspected before or after anesthesia, but often is tolerated better after the use of an anesthetic. Visually inspecting the wound to its complete depth is required to search for foreign bodies and any anatomical injuries. Gentle probing of the wound with forceps will prevent potential injuries to the examiner.
After appropriate anesthesia, wound irrigation can begin. High-pressure irrigation is an effective method for removing bacteria and potentially other infective material; most authorities recommend irrigation with at least 5-8 pounds per square inch. A 19-gauge needle with a 35-65cc syringe has been shown to generate that amount of pressure or more.12 One study that compared different types of methods also validated the use of a splatter shield and a syringe adding some protection against the multitude of biohazards that exist.13
Normal saline is the most commonly used irrigant, though tap water has been shown to be just as effective, readily available, and less expensive.14 Chlorhexidine, hydrogen peroxide, benzalkonium chloride, and detergent-containing products (e.g., Betadine scrub) should not be used for wound cleansing because they can result in local tissue injury and, in some instances, are less effective antimicrobials.15 Most authorities recommend 50-100 mL of irrigant per cm of wound length.16 High-pressure irrigation is not necessary in all wounds, particularly in highly vascular wounds (e.g., on the scalp and face) where there is no difference in the rate or infection or cosmetic appearance.17 There is no utility in soaking wounds; it is not effective and may be detrimental to repair and healing.
Hair removal may make closing the wound edges easier but is not required. Shaving should be avoided because of the potential for increased infection.18 Hair removal should be avoided in the eyebrows; they are important as cosmetic landmarks in closure. In conjunction with irrigation and prior to skin closure, debridement may be necessary. The goal of debridement is removal of devitalized tissue that could increase the risk of infection. Additionally, removing any nonviable tissue around the wound edges may improve cosmetic appearance.
While the above-mentioned techniques are in most standard emergency medicine textbooks, practice among emergency physicians is variable, both in the methods of irrigation and closure. One study of board certified emergency medicine physicians demonstrated that 38% of them soaked wounds; 21% used full-strength (10%) povidone iodine or hydrogen peroxide; 67% scrubbed wounds using cotton gauze or coarse sponges; 27% irrigated wounds with other than recommended irrigation; and 76% never or infrequently practiced delayed primary closure.19
The timing of wound closure is dependent upon a number of factors: location of the wound, the degree of contamination, and the amount of time that has elapsed from the injury to closure. It generally has been an accepted standard that wounds on the extremities can be open for six hours prior to closure, while wounds on the head and neck may have up to 24 hours. Wounds that are at high risk for infection, even after copious irrigation and cleansing techniques, may be candidates for delayed primary closure. Physician judgment is key in making this decision. When in doubt, "one is never wrong not closing a wound." Patients also should be informed that all wound repair leaves scars, that scars sometimes can be revised, and that it will be months before one knows the ultimate result.
It should be emphasized that "closing a wound loosely" or using surgical tape instead of suture are considered primary closure of a wound with all the associated risks of infection and their sequelae.
Amputations
The loss of an extremity or part of an extremity is both a dramatic and emotional event. The advent of microsurgical techniques has significantly improved the potential for outcomes since the first surgical attachment more than 40 years ago.20 Salvage of the body part should begin as soon as the incident occurs with careful attention paid to the tissue itself. Pre-hospital personnel, bystanders, or emergency medicine personnel should place the amputated part in a saline-moistened sponge and then in a plastic bag. This bag should be sealed and placed on ice. Direct contact with the ice should be avoided as it may result in tissue injury. Indications for replantation include multiple-digit amputations; amputations of the thumb, wrist, or forearm; sharp amputations with minimal to moderate avulsion proximal to the elbow; single digits amputated between the proximal interphalangeal joint and distal interphalangeal joint; and amputations in children.20
There are some relative contraindications to replantation. These include patients who are unstable with other life-threatening events, multiple-level amputations, self-inflicted amputations (i.e., the patient may attempt the same thing on the replanted part), extremes of age, or serious underlying diseases (e.g., diabetes or congestive heart failure).20 Single-digit amputations proximal to the flexor digitorum superficialis insertion also are contraindicated; attempts distal to that level may result in suboptimal motor or sensory function.20,21
The mechanism of injury affects prognosis; incisional or guillotine wounds have significantly better results than injuries with crush or avulsion injuries.21 Timing is critical; the maximum ischemia times for reliable success with replantation are 12 hours of warm and 24 hours of cold ischemia for digits and six hours of warm and 12 hours of cold ischemia for replantations that involve muscle.21 The success and indication may ultimately depend upon local availability of consultants experienced in microvascular techniques and the prevailing community standards.
Case #2. Edward and Eileen Rybka v. NYCHHC.22
Edward Rybka, a carpenter, severed the index, middle, and ring fingers of his nondominant hand. He presented to Bellevue Hospital and was taken to surgery four hours later, where the middle and ring finger were reattached successfully by the microsurgery team; they were unable to reattach the index finger. Mr. Rybka brought suit claiming that ice should have been applied to his index finger while the others were being reattached and that the reattachment wasn’t timely on the index finger. The defense claimed that repair of the index finger was timely as evidenced by the viability of the other two fingers and that putting the index finger in ice would have caused ischemic damage. The defense said the loss of the index finger was due to severe damage; Mr. Rybka had lost the index finger from the pip joint distally. He was unable to work for three years. Verdict was for the defense.
Discussion
Establishing a protocol for all amputations is helpful from the time of injury and may include the care of the injured part, the need for imaging, pain control, and early consultation. Patients must know the risk and benefits of everything that may occur. Give the patient a realistic picture of the situation: In amputation cases, regaining functionality with the realization that it won’t be restored to pre-accident levels should be discussed. If the situation for reimplantation is hopeless, both the patient and his family members should be informed. In Rybka, the patient was expecting optimal results in a difficult situation. The ultimate outcome will depend upon the community standard and the availability of surgeons skilled in reimplantation.
Special Situations
Tendon/Nerve Injuries
Wound exploration is critical for determining the presence of foreign matter or joint, tendon, or nerve injuries. Prior to exploration and before anesthesia, a functional examination should be performed to determine the extent of injury. The mechanism of injury should be elicited prior to the examination. In the case of hand injuries, the patient’s dominant hand should be documented. Special attention and further investigation is warranted if the patient complains of pain upon movement, numbness or weakness, or the history and examination are consistent with a fight bite.
The exploration should be performed in a relatively bloodless field after anesthesia with optimal lighting. Methods used include increasing the blood pressure cuff to 20-30 mm above the patient’s systolic blood pressure level for upper or lower extremity injuries. In the case of hand injuries, cutting the finger tips off a surgical glove, putting it on the involved hand, and rolling it down past the wound creates a tourniquet, as well as a sterile field. There also are commercially available finger tourniquets that can be used. Tourniquets should not be placed for prolonged periods of time in the ED.6
Examine the wound with good range of motion; the location and mechanism of the injury may prevent an easy visual inspection of the tendons. As much as possible, the physician should recreate the mechanism of injury. Inspect the wounds for any degree of tendon sheath or tendon involvement. Tendon repair may be done either primarily or in a secondary fashion depending upon the type of wound involvement, the presence of foreign matter, whether the flexor or extensor tendon is involved, and any other injury the patient may have. Flexor tendon injuries to the hand need to be repaired by a hand specialist or orthopedic surgeon. Primary repair is recommended with most injuries being repaired in 12-24 hours.23,24 In the event of excessive contamination, skin loss, unstable bony injuries, or missing tissue, delayed closure up to two to three weeks after the injury is possible with little difference in outcomes.23,24
Extensor tendon injuries can be repaired by emergency physicians depending upon the location and the physician’s comfort level. Repair can be performed by the emergency physician if he is qualified to do it and can arrange appropriate follow-up care, if the laceration is between the distal wrist and metacarpalphalangeal joint; is fewer than 8 hours old; or the skin and tendon wounds are sharp, easily visualized, and not heavily contaminated.24 Not all tendon injuries need repair; most tendon lacerations that are less than 50% can be treated without surgery.23
Nerve repair — like tendon repair — may be done either primarily or in a secondary fashion. By definition, primary repair is done within five to seven days of the injury and is most effective when the nerve ends can be re-approximated without tension in a well-vascularized area.25
Secondary repair generally is performed two to three weeks later and can involve either re-approximating the nerve ends or grafting. Most repairs are performed on the upper extremities, although they can be done in the lower extremities with mixed results.25 For all nerve injuries, there is better success in younger patients or in patients with a cleaner mechanism of injury.
Case #3. Joseph and Tonya Luby v. H Arthur Heafer, MD, and Susan Galbele.26
Joseph Luby sustained a laceration to the distal joint of his left index finger when he accidentally closed the finger in a bank’s night deposit drawer. He presented to Presbyterian Hospital-Kaufman ED for treatment. The wound was cleaned and sutured by a physician assistant under the supervision of a Dr. Heafer. When Mr. Luby failed to regain movement of the distal finger joint after 30 days, he was sent to a hand surgeon who discovered a previously undiagnosed rupture to the flexor profundus tendon at the site of the previous injury. A complex tendon transplant procedure followed but still left Mr. Luby with a deformed and disabled finger. Mr. Luby brought suit, claiming that the tendon injury should have been discovered on the original visit when a simple repair could have been done easily and successfully. He also claimed that the delay led to a more complicated surgery that was unsuccessful. The case was settled for a confidential amount.
Case #4. Wanda Collazo v. New York City Health and Hospitals Corp.27
Miss Collazo, an 8-year-old girl, had an injury to her right foot with severance of three tendons that was not recognized by the ED physician. She was examined in the ED of Jacobi Hospital where a simple repair of the skin was done. She returned two days later for a recheck; the foot attitude had changed to a 45-degree angle downward. Primary repair was not considered an option at that point due to possible infection. A surgeon recommended tendon grafting, which was done, but the patient developed an abnormal gait and was unable to extend three toes. She was able to wear only sneakers and was unable to participate in athletics or dance. She brought suit, claiming the difficulty in moving her toes was overlooked. The defendant physicians said that they had considered tendon injury, but that the decision to observe and follow-up had been appropriate. A verdict of $1.2 million was awarded.
Discussion
Patients should be involved in the decision-making process as much as possible. Explaining the potential for infections, the type of repair, and the expectation of function after repair are all important elements. There also may be individual variations among consultants, and the emergency physician should discuss that possibility with the patient. Although many of these injuries may be repaired acutely, it is possible that an orthopedic surgeon may want the skin closed primarily and the injured extremity splinted with follow-up care arranged as an outpatient. Most patients requiring surgical intervention often may be discharged after appropriate follow-up care is arranged.28
Foreign Bodies
The approach to wound care should be very systematic — even protocol-driven — for all patients presenting to the ED. The mechanism of injury should be solicited with careful attention paid to the normal function of the injured area. There always should be a concern for foreign bodies with a high index of suspicion in certain animal bites or grossly contaminated wounds; the mechanism of injury may be a clue to their presence. For example, a wound caused by sliding on gravel should heighten the suspicion for retained fragments, while a puncture with a knife will be less suggestive. Additional clues would be persistent pain, drainage, or wounds that otherwise fail to heal. Interestingly, patients with glass injury may be able to feel the presence of the foreign body; it may be useful to ask them.29
Imaging techniques for foreign bodies consist of many modalities; their effectiveness is variable and dependent upon the material of the foreign body. Radiography is readily available and may locate a number of materials, including metal, bone, teeth, pencil graphite, certain plastics, glass, gravel, sand, some fish bones, some wood, and some aluminum.30 Glass does not need to contain lead to be visible on x-ray, and glass fragments 2 mm or larger are visible on x-ray.30
Computed tomography (CT) imaging can detect more types of foreign material than radiographs and is 100 times more sensitive in differentiating densities.28 Some wood, thorns, and spines not visible on plain radiographs have been identified with CT imaging. However, its expense and radiation exposure does limit its utility.
Ultrasonography also is an option, but there is variable success with it. The overall sensitivity ranges from 50-90%, and specificity is 70-97% for gravel, metal, glass, cactus spines, wood, and plastic.30 Magnetic resonance imaging (MRI) also is available, but because of its limited use in wounds that involve gravel or metal, it probably should be reserved for suspicion of vegetative matter that is not seen on other imaging techniques.30
The need for foreign body removal is dependent upon its location and the type of material; vegetative material is markedly more reactive than metal. The benefit of removal should be weighed against the trauma and tissue destruction that may occur.
Case # 5. Blomberg v. Greenlaw and Sobky.31
Mr. Blomberg was a passenger in a car that ran off the road. When he was helping the tow truck crew retrieve the car, he slipped into the culvert and suffered an open dislocation of his thumb with bone protruding through skin. The 48-year-old man popped it back into place himself and went to an ED. There, an x-ray revealed foreign matter in the wound. Dr. Greenlaw cleaned and sutured the wound and instructed the patient to take antibiotics and follow up with his doctor for suture removal in one week. The next day, Mr. Blomberg went to another ED complaining of flu symptoms and pain in the hand and saw Dr. Sobky. A repeat x-ray still showed foreign matter. The wound was redressed; Mr. Blomberg was given a pain injection, and told to follow up with his primary care physician in three days. He then developed increased pain, oozing from the wound, and foul odor. His physician saw him two days after the ED visit and ordered immediate surgery for cleaning and debridement of the infected joint. Mr. Blomberg eventually required a fusion of the thumb after recurrent infection. He sued Drs. Greenlaw and Sobky, claiming that the defendant physicians failed to properly clean the wound and refer to him to a specialist. The defense said that the patient should have returned at first signs of infection. A verdict for the plaintiff was for $475,000; fault was attributed at 50% to first ED physician, 30% to the second ED physician, and 20% to the patient, for a net recovery of $380,000.
Case #6. Ashley v. Gustafson, et al.32
Ms. Ashley, a 44-year-old female, had put broken glass in a trash bag and failed to notice that a piece was jutting out from the bag. While walking past the bag, she cut her ankle on the protruding glass. A physician in the ED saw her and sutured the wound. No x-ray was performed. A second physician saw her nine months later for persistent pain and removed a 2.5-cm piece of glass from the wound; he also did not x-ray her. Seven months later, she returned to the ED with more pain, and an x-ray was done, revealing three more pieces of glass. Ms. Ashley filed a suit, claiming that an x-ray was required for this type of wound. The defendants claimed x-ray was not needed for this wound. A verdict for $179,000 was returned, but reduced to $119,930 after fault was allocated. Fault was designated as 42% to the first ED physician, 25% to the second ED physician, and 33% to the plaintiff.
Discussion
The mechanism if injury may be a clue to the potential for foreign bodies. In a situation where glass is involved, the potential for multiple pieces exists and having a high index of suspicion is very important. If one foreign body is found, be vigilant in looking for additional pieces, remembering the adage "where there’s smoke, there’s fire." Educate the patient and/or the family about the potential for foreign bodies and the potential for wound infection. Document that a search was performed and give good wound care and follow-up instructions.
As the above cases illustrate, a patient also is responsible for affirmative participation in optimizing his or her outcome. In some cases, the patient may not follow directions, comply with medication administration, or show up for subsequent appointments. In these situations, the court or jury may hold the patient partially liable and reduce the award proportionally if a bad outcome occurs. This legal concept is referred to as contributory negligence or comparative fault.
Patients may not have the ability to accurately identify and assess wound healing properly.33 Follow-up instructions should be very explicit, especially for wounds that are high risk. Specific wound care instructions should be in the form of a written document, and patients should be told to return for any signs of swelling, redness, or fever. All high-risk wounds should have a mandatory 24-to 48-hour recheck.
In general, there is no utility in antibiotic prophylaxis for uncomplicated wounds.34
There are certain factors, however, that are associated with an increase in wound infections: advanced age, history of diabetes, the presence of foreign body in the wound, stellate shape of the wound, a wide laceration, jagged wound edges, and wounds deeper than the subcutaneous tissue.35 Many authorities recommend antibiotics in immunosuppressed hosts; open fractures; wounds involving exposed tendon, bone, or joint; grossly contaminated high-risk bite wounds (e.g., puncture, crush, or extremity); oral wounds; or those that have significant delay before presentation.5 Giving unneeded medication is not without risk; it can result in side effects, allergies, or hypersensitivity.
Case # 7. DeJesus v. Burchett and Adkins.36
Mr. DeJesus worked for a company that refurbished acid washer tanks. A large piece of equipment fell on his arm, resulting in a significant laceration/crush injury.
He was transported by ambulance to St. Joseph’s ED and treated by Dr. Burchett and physician assistant Adkins. The wound was cleaned and sutured, and the patient was discharged. No x-ray was taken.
Three months later, Mr. DeJesus saw Dr. Stearns, an orthopedist, who performed an x-ray revealing foreign bodies in the patient’s arm that appeared to be shards of glass. One week later, surgery was performed to remove some of the fragments of glass, but an additional piece was unrecognized during the surgery. The orthopedist noted ongoing pain, numbness, weakness, and limited motion in the arm.
Mr. DeJesus brought suit contending that the original providers were negligent in not providing antibiotics or getting an x-ray that would have revealed the glass. The defendants claimed that the pain was due to the original crush injury and not to the glass. They also claimed that the x-ray was not indicated in a superficial injury that had been examined thoroughly, stating that it is more risky to remove an inert foreign body than to chase after it. They also claimed that there was no harm and that the patient would have had pain anyway.
The jury found the defendants negligent but awarded no damages. The judge ordered a new trial based on the evidence that was uncontroverted that an additional surgery had been performed, and thus, there had been harm. The orthopedist, Dr. Stearns, served as an expert witness for the plaintiffs.
High-Risk Wounds
There are many high-risk wounds that merit additional discussion, including high-pressure injection injuries, plantar puncture wounds, and animal bites, all of which can be potentially devastating. Because many of these are puncture wounds by mechanism, the full extent of the injury may not be identified unless the ED physician substantially increases the size of the wound. This lack of recognition and treatment can result in substantial morbidity.
High-pressure injuries often present as small puncture wounds that most commonly involve the hand. Although they may appear innocuous to both the patient and health care provider, a lack of vigilance in caring for these patients can result in disastrous consequences. High-pressure spray guns can discharge a variety of products (e.g., water, paint, thinners, solvents, and hydraulic oil and fluid).
Factors that affect morbidity include the site of injection and the type, amount, viscosity, and pressure of the material injected.37 Solvents and paint thinners are significantly more damaging than grease and oil-based compounds; the lower viscosity allows an easier spread of the injected material.38 If the material is injected into a relatively nondistensible tissue (e.g., a finger), there will be an increase in tissue pressure, resulting in tissue damage and compromise of the microcirculation resulting in a compartment-like syndrome.39 The injury often occurs in the nondominant hand while a worker is clearing equipment or trying to steady it during its operation.
Plain film radiographs may reveal varying distribution of radio-opaque densities associated with paint or subcutaneous air from air or water injection. While imaging may be important, consultation with a hand surgeon should be done expeditiously; the amputation rate is significantly greater if surgical debridement occurs more than six hours from the time of injury and varies from 16-55% of patients.38
Plantar puncture wounds are another important and controversial area of wound management. There are a multitude of strategies proposed for their management with no definitive proof that any one is the best. For simple puncture wounds without concern for contamination, many physicians would advocate simple follow-up for wound checks.40 Wounds that are grossly contaminated, occur over the metatarsal phalangeal joints, or in patients who have had an injury that involves a rubber-soled shoe (e.g., a tennis shoe) are at risk and may need to be debrided.41,42 The decision to treat with antibiotics is controversial and should be aimed at the extent of the wound and other risk factors. These wounds should have radiographic evaluation if there is a suspicion for foreign bodies. Wounds that are infected already may need debridement, especially if there is a concern for foreign bodies.42 The most commonly involved organisms are Staphylococcus and Pseudomonas organisms. Therapy should be determined based upon the age of patient and the cause of the infection. Given the controversial nature of this injury, explaining the options available and the risk/benefit to the patient may be helpful.43 These wounds also should be considered high risk with mandatory follow-up.
From 500,000 to 4.5 million Americans are bitten by animals every year.44 Animal bites account for 5% of the total number of traumatic wounds evaluated in EDs and approximately 1% of all ED visits.45 Dog bites cause the majority of injuries, followed by cat and human bites; 3-18% of dog bites and 28-80% of cat bites may become infected.46 These wound infections are associated with occasional sequelae including meningitis, endocarditis, septic arthritis, and septic shock.46
Dog bites account for 80-90% of all bites, and most commonly involve the extremities but primarily affect the head, face, and neck in young children.47 Contrary to older studies, recent data have shown Pasteurella multicida as the most common organism involved in dog bites followed by streptococci and staphylococci.46
Cat bites are the second most common bite and commonly involve the extremities — particularly the hand — with the majority being puncture wounds. This factor may contribute to the higher incidence of infection. Pasteurella is the organism responsible in the majority of cases.46
Human bites can be divided into occlusional bites and hand bites involving the metacarpal phalangeal (MCP) joint (e.g., clenched-fist injuries). Occlusional bites occur when the teeth break the skin, often tearing the tissue and leaving bite marks. When they occur in places other than the hand, they are no more dangerous than any other laceration or bite.47 MCP injuries, however, often occur in younger men as a result of an altercation and are at substantial risk for infection. The extensor tendon often retracts proximally after the injury, seals the puncture, and creates an anaerobic environment for inoculated bacteria within the joint.48 There is a basic axiom in emergency medicine: Any wound over the hand MCP joint is a fight bite until proven otherwise. Care must be taken to explore these wounds; many of them may need hand surgeon referral. The organisms involved include Streptococcus and Staphylococcus aureus, but there also is a high percentage of anaerobes involved.49
The use of antibiotics for animal bites is controversial. The decision to treat should be an individualized decision based upon the type and location of the bite, the age of the patient, associated medical conditions, the presence of high-risk criteria, and the time of injury. There are many risk factors identified where antibiotics may be useful: deep puncture wounds, wounds with extensive crush injury, those involving underlying tendons and muscle, retained foreign bodies, underlying fracture, or penetration into joint spaces in general, and bites on the hand and lower extremities by cats, and patients older than 50 years.47,50 Additional risk factors may include patients at risk for endocarditis, those with orthopedic prosthesis, immunocompromised patients, and those with bites involving lymphedematous tissue.50
Antibiotics should not be used as a substitute for proper local wound care.5,50 The decision for primary closure also should be individualized; the amount of contamination is a deciding factor. Most animal bite wounds on the face can be closed. Wounds on the distal extremities — especially the hands and feet — probably should not have primary closure, but again, decisions should be individualized.45,51
Many studies addressing those issues suffer from a lack of clinical numbers and a prospective approach. A recent Cochrane Database review of randomized controlled trials cited no evidence for the use of prophylactic antibiotics for cat or dog bites, but stated that there may be some utility in their use in human bites and bites of the hand.52
The emergency physician or nurse should inquire about the patient’s tetanus status on every ED encounter and document the status on the medical record. Older Americans, some immigrants, and the poor are all at risk for being under immunized.
Tetanus-prone wounds include those older than six hours; deep punctures; and contaminated, infected, or denervated wounds. These wound types require relatively liberal treatment. Treatment ranges from the use of a tetanus and diphtheria (Td) booster — if the patient hasn’t had one within five years — to the use of human tetanus immunoglobulin (TIG) for those individuals who have not received a primary series of three tetanus immunizations.
Case #8. Bessenyei v. Raiti.53
Mr. Bessenyei had paint thinner injected into his thumb under high pressure and presented to the ED for this injury.
Dr. Raiti, the ED physician, consulted a hand surgeon, who was not on call but previously had demonstrated a willingness to help. The hand surgeon recommended antibiotics and pain medications, which the patient was given. Mr. Bessenyei had his tetanus immunization updated and was discharged with instructions to return if his condition worsened. His thumb worsened, and a partial amputation subsequently was necessary.
Mr. Bessenyei sued both physicians claiming that they negligently failed to realize the seriousness of a high-pressure injection and appropriately incise and debride his thumb. The hand surgeon asked the judge to dismiss him from the case because he had no relationship to the patient or contractual duty; he simply had provided advice. The judge agreed and held the ED physician solely liable, stating, "It was Dr. Raiti (ED physician) who had direct contact with the patient, rendered care, and initiated contact with the consultant. He could override the consultant by accepting or rejecting his recommendations and made the final decision."
Discussion
Given the high potential for amputation and the fact that early care makes a difference, high-pressure injection injuries should be evaluated and physically seen by a hand surgeon in an expeditious fashion. The emphasis to the consultant should be that these patients need operative intervention.
In general, a consultation via the phone does not establish a physician-patient relationship; thus, the consultant cannot be held liable for malpractice related to advice. Most courts require an actual examination by the physician to establish a relationship or a very specific and affirmative action by the physician that establishes that he agrees to be involved in the patient’s care. The courts are hesitant to have mere conversations — even in on-call situations — or an agreement to follow-up care as establishment of a formal relationship because to allow those would chill the normal communication of professionals that usually facilitates optimal patient care.
Expert Witness in Wound Care
In cases of alleged medical malpractice, a physician witness almost always will be called to provide expert testimony. The qualifications and eligibility of who is actually able to provide expert testimony can be contentious, especially in areas of medicine that overlap several specialties such as wound care.
• In Thompson v. Carter,54 the court gave a good overall definition of who can provide expert testimony. The court stated, "Generally, if scientific, technical, or other specialized knowledge will assist the trier of fact (jury) to understand the evidence or to determine a fact in issue, an expert witness may testify thereto in opinion form or otherwise. A witness may qualify as an expert based on his knowledge, skill, experience, training, education, or a combination thereof. Qualification as an expert does not necessarily rest upon the educational or professional degree a witness possesses. Simply put, before one may testify as an expert, that person must be shown to know a great deal regarding the subject of his testimony." The following cases will illustrate the wide reach of this concept:
• In Weinberg v Geary,55 a licensed plastic surgeon performed a breast reduction and chin liposuction on the plaintiff. Later, a facelift was done. The plaintiff claimed embarrassing scarring of the breasts, chin, and face. The plaintiff utilized a recently retired orthopedic surgeon as an expert witness and was awarded $500,000. The award was appealed with the claim that the expert was not qualified to give testimony. The appeals court affirmed the first decision and noted the expert had graduated with honors from medical school, had practiced in the state ever since, was board certified in orthopedics, and had sutured more than 10,000 wounds. He was familiar with suturing techniques. Thus, he was allowed as an orthopedist to testify against a plastic surgeon.
• In Sami v. Varn,56 an obstetrician/gynecologist was ruled qualified to testify as an expert against an ED physician. The plaintiff Vida Sami presented to an ED with vaginal bleeding, pain, and pregnancy. She was examined by the ED physician Dr. Varn and subsequently by Dr. Dill, a resident in obstetrics/gynecology (OB/GYN). The diagnosis of spontaneous abortion was made. Months later, she was seen by Dr. Roberts, an obstetrician/gynecologist, who found an abdominal mass on ultrasound. In surgery, the mass was discovered to be a second uterus containing a 12-15 week dead fetus. Ms. Sami then sued the ED physician and hospital for negligence. She used Dr. Roberts as an expert witness, but the trial court ruled he was not qualified to give expert testimony against ED physicians, and the case was dismissed. On appeal, the Virginia Supreme Court reversed the ruling and noted that a witness is qualified to be an expert on the standard of care if he demonstrates knowledge of the defendant’s specialty and has had clinical practice in that specialty or a related field of medicine. The court explained that the standard of care for performance of an adequate pelvic examination is common to both ED and OB/ GYN specialists. Wound preparation, closure techniques, and even the use of antibiotics may be different for other specialties, such as plastic surgery and orthopedics, whose practitioners may be allowed to testify as expert witnesses in court.
It is clear that it behooves the ED physician to be familiar with other specialists’ approach to various situations in wound care because they may later find them giving expert testimony against them. This endeavor will allow them to provide a standard of care that satisfies the expectations of multiple specialties.
Summary
Wounds in the ED are a common source of medical claims. There are a variety of controversies involving the type, location, need for closure, and the use of antibiotics. However, the use of good wound preparation and involvement of the patient in the decision-making process may help in the management of risk. The above Table summarizes some basic wound pearls.
Endnotes
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4. Henry GL. "Specific High-Risk Medical-Legal Issues." In: Henry GL, Sullivan DJ, eds. Emergency Medicine Risk Management. Dallas: American College of Emergency Physicians; 1997, pp. 475-494.
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6. Hollander JE. "Patient and Wound Assessment: Basic Concepts of the Patient History and Physical Examination. Foreign Bodies in Wounds." In: Singer AJ, Hollander JE, eds. Lacerations and Acute Wounds: An Evidence-Based Guide. Philadelphia: FA Davis; 2003, pp. 9-12.
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10. Green SM, Krauss B. Clinical practice guideline for emergency department ketamine dissociative sedation in children. Ann Emerg Med 2004;44:460-471.
11. DS, as Trustee for Next of Kin of DS, Decedent v. Hospital. Medical Malpractice: Verdicts, Settlements, Experts 2002;18:3.
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13. Pigman EC, Karch DB, Scott JL. Splatter during jet irrigation cleansing of a wound model: A comparison of three inexpensive devices. Ann Emerg Med 1993;22:1,563-1,567.
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18. Seropian R, Reynolds BM. Wound infections after pre-operative depilation vs. razor preparation. Am J Surg 1975;129:251-254.
19. Howell JM, Chisolm CD. Outpatient wound preparation and care: A national survey Ann Emerg Med 1992;21:976-981.
20. Shlenker JD, Koulis CP. Amputations and replantations. Emerg Med Clin N Am 1993:11:739-753.
21. Wilhelmi BJ, Lee WP, Pagensteert GI, et al. Replantation of the mutilated hand. Hand Clin N Amer 2003;19:89-120.
22. Edward and Eileen Rybka v. NYCHHC, New York County Supreme Court, Index No. 111173-97.
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26. Joseph and Tonya Luby v. H. Arthur Heafer, MD, and Susan Gabele, Kaufman County (TX) District Court Case No. 58532.
27. Wanda Collazo v. New York City Health and Hospitals Corp., Bronx County (NY) Supreme Court.
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31. Blomberg v. Greenlaw and Sobky, U.S. District Court, Western District of Missouri, Case No. 97-1323-CV-W-9.
32. Ashley v. Gustafson, et al., Jackson County (MO) Circuit Court, Case No. CV97-19936.
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36. DeJesus v. Burchett and Adkins, Lexington County (KY) Circuit Court Case No. 99 CV 0468.
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44. Weiss HB, Friedman DI, Coben JH. Incidence of dog bite injuries treated in emergency departments. JAMA 1998;279:51-53.
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47. Griego RD, Rosen T, Orengo IF, et al. Dog, cat, and human bites: A review. J Am Acad Dermatol 1995;33:1,019-1,029.
48. Basadre JO, Parry SW. Indications for surgical debridement in 125 human bites to the hand. Arch Surg 1991;126:65-67.
49. Goldstein EJ. Management of human and animal bite wounds. J Am Acad Dermatol 1989;21:1,275-1,279.
50. Dire DJ. "Animal bites." In: Singer AJ, Hollander JE, eds. Lacerations and Acute Wounds: An Evidence-Based Guide. Philadelphia: FA Davis; 2003, pp. 133-147.
51. Dire D. Management of mammalian bites. Acad Emerg Med 1994;1:178-180.
52. Medeiros I, Saconato H. Antibiotic prophylaxis for mammalian bites. Cochrane Database Syst Rev 2003;2:CD001738.
53. Bessenyei v. Raiti, U.S. District Court-Maryland, No JFM-01-1029 (June 9, 2003).
54. Thompson v. Carter, 518 So. 2d 609 (MS) (1987).
55. Weinberg v Geary, 686 N.E.2d 1298 (Ind. Ct. App. 1997).
56. Sami v. Varn, No. 992345, Virginia Supreme Court (Sept 15, 2000).
The authors of this issue point out that 3-11% of malpractice dollars paid are disbursed for wound-related cases. Although wound infections may occur despite proper wound care, the detection of tendon or nerve injuries as well as joint violations requires a higher index of suspicion. This months review of wound management and its pitfalls serves the reader well by keeping the practitioner attentive to the potential problems of wound care.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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