CHAPTER 2

Patient Evaluation
and Wound Assessment
Key Practice Points
nn To

prevent unexpected syncope and to provide for patient comfort

during wound care, the patient is placed in the supine position.
Parents or friends, who want to stay with the patient, are at risk as
well.
nn Most bleeding can be stopped with simple pressure. Blind instrument
clamping is avoided.
nn All rings and jewelry are removed from the wound area to prevent
ischemia as a result of swelling.
nn All wounds are contaminated with bacteria and should be cleansed and
irrigated early after arrival if care is to be delayed beyond 1 to 3 hours.
nn Severe soft tissue injury is an emergency and requires rapid and
aggressive care.
nn Small, innocuous wounds can be caused by more serious problems
such as cardiac arrythmias.

INITIAL STEPS
Patient Comfort and Safety

If there is the slightest question about a patients ability to cope with his or her injury,
the patient is placed in a supine position on a stretcher. Loss of blood, deformity, and
pain are sufficient to provoke vasovagal syncope (fainting), which can cause further
injury from an unexpected fall during evaluation or treatment. The attire of the caregiver should be consistent with universal precautions. Because wound care can be strenuous, the caregiver should be comfortable and relaxed before proceeding. Sitting, when
possible, is recommended.
Relatives or friends accompanying the patient also can respond in a similar manner. As a rule, relatives and friends are encouraged to sit in the waiting area unless the
physician or nurse determines that staying with the patient would be beneficial (e.g., to
comfort an injured child). The parent or friend should be asked if he or she feels comfortable with that arrangement.

Initial Hemostasis

Most bleeding can be stopped with simple pressure and compression dressings. There is
no need for dramatic clamping of bleeders. Clamping is reserved for the actual exploration and repair of the wound under controlled, well-lighted conditions. Blind application
of hemostats in an actively bleeding wound can lead to the crushing of normal nerves,
tendons, or other important structures.
4
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CHAPTER 2 Patient Evaluation and Wound Assessment

Jewelry Removal

Rings and other jewelry must be removed from injured hands or fingers as quickly as
possible. Swelling of the hand or finger can progress rapidly after wounding, causing
rings to act as constricting bands. A finger can become ischemic, and the outcome can
be disastrous. Most items of jewelry can be removed with soap or lubricating jelly. Occasionally, ring cutters have to be used (Fig. 2-1). The sentimental value of a wedding ring
should never be allowed to impede good medical judgment. A jeweler always can restore
a ring that has been cut or damaged during removal. Another technique for removing
rings (steel, titanium) that cannot be cut is described in Chapter 13.

Pain Relief

Pain relief begins with gentle, empathic, and professional handling of the patient. Occasionally, it is necessary to administer pain-reducing or sedative medications to patients
being treated in the emergency wound care setting. Sedation and specific pain relief
measures are discussed more completely in Chapter 6.

Wound Care Delay

If there is going to be a delay from initial wound evaluation to repair, the wound is covered
with a saline-moistened dressing to prevent drying. The dressing need not be soaked and
dripping wet. Delays that extend beyond 1 hour require that the wound be thoroughly
cleansed and irrigated before the saline dressing is applied.1 If extended delays are inevitable, antibiotics occasionally are considered to suppress bacterial growth. If antibiotics
are administered, they should be given early to provide the maximal protective benefit.2,3
Chapter 9 discusses further recommendations for the early administration of antibiotics.

Children with Lacerations

Particular care must be taken with children who have wounds and lacerations. The pain
and fear generated by the experience can be reduced significantly by a few simple measures. The child should be allowed to remain in the parents lap for as long as possible
before wound repair. Most of the physical examination can be performed at that time.
If hemostasis is required, and if the parent is willing to cooperate, he or she can be
allowed to tamponade small, bleeding wounds. Parents also can apply topical anesthetics. Careful judgment has to be used when handling children and their parents. It is
common for some parents to be unable to tolerate the sight of their child in pain, and
they often do better in the waiting room while care is being delivered. It is remarkable
how some children stop crying when the parent has left the treatment area. Pediatric
considerations in wound care are discussed in detail in Chapter 5.

Severe Soft Tissue Injuries

Providers of emergency wound care occasionally are confronted with patients who have
severe, but not life-threatening, soft tissue injuries, usually of the distal upper or lower
extremities. Power tools, industrial machines, farm implements, and mowers commonly
cause these injuries. Patients often present with extensive skin lacerations, combined
with varying degrees of nerve, tendon, or vascular involvement. On the patients arrival
at the emergency department, several steps, outlined here, are performed to ensure the
stability and comfort of the patient and to evaluate and protect the injured limb. These
injuries may include an amputated part; guidelines for the management of that part are
described in Chapter 13.
ABCs (airway, breathing, circulation): Because of the severity of these injuries, the airway and
vital signs are assessed to ensure the stability of the patient. A brief history and general
system survey are carried out to rule out any secondary injuries or modifying conditions.

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CHAPTER 2 Patient Evaluation and Wound Assessment

B
Figure 2-1. A, Ring removal. Rings can be removed with a ring-cutting device. A through-and-through cut
is made at the thinnest portion of the ring. B, Large hemostats are clamped to each side of the cut portion.
Taking care not to harm the finger, the ring is gently pried open.

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CHAPTER 2 Patient Evaluation and Wound Assessment

Hemorrhage:

Any bleeding, as described earlier, is controlled by direct pressure.

Tourniquets are indicated only for severe bleeding of an extremity that cannot be
controlled by direct pressure, which is a rare occurrence. Should a tourniquet be
necessary, proper technique must be observed. Edlich etal. recommend that after
elevating the injured extremity for 1 minute, the blood pressure cuff is inflated to the
lowest pressure that will arrest the bleeding. This measured level of inflation can be
maintained for at least 2 hours without injury to the underlying vessels and nerves.4
Pain relief: The most effective pain relief for severe hand or foot injuries is nerve blockade with local anesthetics. Nerve blocks are performed only after sensory and motor
function is evaluated and documented (see Chapter 6 for nerve block techniques).
Pain relief for adults also can be accomplished with parenteral (intravenous or intramuscular) medications, meperidine (Demerol), 25 to 50 mg, or morphine, 2 to 5 mg.
These medications can be supplemented with promethazine (Phenergan), 12 to 25
mg to reduce the possibility of vomiting. See Chapter 5 for pain relief in children.
Tetanus immunization: Because patients with severe soft tissue wounds are more likely
to be at risk for tetanus, tetanus immunization status has to be determined. See
Chapter 21 for immunization recommendations.
Antibiotic prophylaxis: Because of the severe nature of these wounds, they are susceptible to infection. The most common organisms cultured from these wounds are Staphylococcus aureus and -hemolytic streptococci.5 Coliforms and anaerobes are cultured
in smaller numbers. The most feared organisms are the soil-borne Clostridium species,
but these rarely cause infection. Wounds caused by tools and industrial machines
are predominantly contaminated with gram-positive organisms.6 Farm implements
and gardening tools that come in contact with soil have a higher proportion of coliforms. These differences have implications in the selection of antibiotics. For clean,
nonsoil-laden wounds, a first-generation cephalosporin provides adequate coverage.
In patients with severe allergies to penicillin or cephalosporins, vancomycin can be
given. In soil-laden wounds, the addition of an aminoglycoside provides good coverage. It cannot be overemphasized that antibiotics are no substitute for aggressive
wound cleansing, irrigation, and dbridement.
Wound evaluation: A functional examination is performed and documented. Loss of
pulse or circulation is a serious finding and requires emergent intervention. Sensory
and motor function is evaluated and documented. Tendon function is tested by individual or group action when possible. All severe soft tissue wounds are radiographed
to assess bone integrity and the presence of foreign bodies.
Wound management: For the most part, little can be done for these wounds in the
emergency department. Loose, gross contaminants can be removed. After evaluation,
the wound is covered with sterile gauze pads and a wrap is moistened with sterile
saline. Appropriate splints are applied as indicated.
Consultation: These wounds require definitive care by consultants with expertise in managing severe extremity and soft tissue injuries. Most commonly, plastic or hand specialists are consulted early after the arrival of the patient. The operating team is notified
early as well to prepare for the definitive care of the patient in the operative room.

WOUND EVALUATION AND DOCUMENTATION

Basic History

The historical items collected and recorded in the wound care patients medical record
need not be lengthy and excruciatingly detailed. Key facts, such as mechanism, age of
wound, allergies, and tetanus immunization status, are virtually always pertinent.
The patients current and past medical history and present medications are
frequently elements of the wound care assessment. Diseases such as diabetes and

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CHAPTER 2 Patient Evaluation and Wound Assessment

peripheral vascular disease can increase the risk of wound infection and cause delayed or
poor wound healing.7,8 Corticosteroids are known to affect the normal healing process
adversely.9 Finally, a careful detailing of allergies is necessary to prevent an untoward
reaction to local anesthetics or antibiotics that might be administered to the patient.
Box 2-1 presents the basic history and physical examination elements of a wound care
charting document.10

Screening Examination

The examination of every patient with a laceration or injury includes assessing the basic
vital signs. Each vital sign can provide information pertinent to the management of the
patient. Hypotension and tachycardia are the classic signs of hypovolemia. Innocuouslooking scalp wounds can bleed profusely, causing clinically significant blood loss with
concomitant hypotension. Because alcohol is a cutaneous vasodilator, this complication is common in intoxicated patients.
Wounds and lacerations are often the result of or the cause of systemic problems
and illnesses. Patients who fall and sustain minor injuries may need to be questioned

BOX 2-1

Elements Recommended for Documentation of Wound Evaluation

and Care*

Wound History
Mechanism of injurywhat happened, possible foreign body
Age of woundwhen it happened
Associated symptomssystemic, numbness, loss of function
Past/Social History
Underlying disordersdiabetes, seizures
Allergiesdrugs, anesthetics
Date of last tetanus
Medicationsanticoagulants, corticosteroids
Vocation/avocation
Handedness
Physical Examination
Vital signs
General/system findings as appropriate
Wound description
Location
Length/extent
Depth
Conditionclean, contaminated, sharp, irregular
Functional examinationas appropriate
Procedure
Anesthesiatype, amount
Wound cleansingagent, irrigation
Exploration/dbridement
Suture type, size, number
Dressing type
Disposition
Wound care instructions (see Chapter 22)
Interval for suture removal
*Elements vary by patient and circumstances.

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CHAPTER 2 Patient Evaluation and Wound Assessment

and examined for causes of syncope. When caused by blunt trauma, a scalp laceration
has the possibility of being associated with a serious intracranial injury. In addition to
the wound assessment, a trauma-oriented neurologic examination is often necessary.
A rapid general survey of the patient can reveal other injuries not reported. Because
of the nature of a traumatic occurrence, patients often cannot report accurately all that
has happened to them. A man who falls on an outstretched hand may be aware only
of a bleeding hand laceration on arrival at the emergency department. An underlying
radial head fracture might be revealed only when the caregiver examines the elbow and
provokes pain.

Wound Assessment

When the wound is examined, several features and findings must be noted and recorded
in the medical record (see Box 2-1). Each wound characteristic and examination finding
becomes a significant variable that influences repair decisions and all aspects of care,
including wound preparation, anesthesia, closure strategy, and dressing choice.

Procedure Documentation

After performing the wound care intervention, whether suturing, foreign body removal,
or burn care, a succinct but detailed procedure note is entered into the record. The elements of the procedure note for suturing are outlined in Box 2-1.

Patient Disposition and Follow-up

When care is completed, instructions for wound care, return for suture removal, and
follow-up care are provided to the patient and are documented. Details of follow-up
care are discussed in Chapter 22.

References

1. Robson MC, Duke WF, Krizek TJ: Rapid bacterial screening in the treatment of civilian wounds, J Surg Res
14:426430, 1973.
2. Burke JF: The effective period of preventive antibiotic action in experimental incisions and dermal
lesions, Surgery 50:161168, 1961.
3. Morgan WJ, Hutchinson D, Johnson HM: The delayed treatment of wounds of the hand and forearm
under antibiotic cover, Br J Surg 67:140141, 1980.
4. Edlich RF, Rodeheaver GT, Thacker JG, etal: Revolutionary advances in the management of traumatic
wounds in the emergency department during the last 40 years: part 1, J Emerg Med 20:111, 2008.
5. Charalambous CP, Zipitis CS, Kumar R, etal: Soft tissue infections of the extremities in an orthopaedic
center, J Infect 46:106110, 2003.
6. Hoffman RD, Adams BD: Antimicrobial management of mutilating hand injuries, Hand Clin 19:3339,
2003.
7. Altemeier W: Principles in the management of traumatic wounds and in infection control, Bull N Y Acad
Med 55:123138, 1979.
8. Hunt T: Disorders of wound healing, World J Surg 4:271277, 1980.
9. Pollack S: Systemic medications and wound healing, Int J Dermatol 21:489496, 1982.
10. American College of Emergency Physicians: Clinical policy for the initial approach to patients presenting
with penetrating extremity trauma, Ann Emerg Med 23:11471156, 1994.

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