Musculoskeletal and Wound Emergencies Study Guide for the CEN

Wound

A wound is any opening in the skin and can be acute or chronic. These openings in the skin increase the patient’s risk of infection. Most wounds are able to heal independently, but some require surgical repair. Underlying conditions such as diabetes, peripheral vascular disease, or autoimmune disorders all affect the patient’s ability to heal.

Avulsions and Degloving Injuries

An avulsion injury occurs when a portion of tissue is torn in any way. This can refer to bone, muscle, tendon, ligaments, or skin. A degloving injury refers specifically to completely tearing skin and tissue away from the underlying structures. If a degloving injury occurs on a patient’s hand, it often looks as if a glove has been removed, hence the name.

Assessment

The symptoms depend on the specific type and location of the injury. A degloving injury is immediately obvious at first glance. The patient will experience severe pain, have profuse bleeding, and have a highly visible traumatic wound.

An avulsion injury to the skin or soft tissue will be obvious if the skin is broken, but may not be obvious until imaging is performed if only the underlying structures are affected. An X-ray will reveal damage to any underlying structures and the presence of any foreign bodies.

A CBC will be performed to measure the patient’s hemoglobin and hematocrit levels. A type and screen will determine the patient’s blood type and Rh factor if a blood transfusion is needed.

Treatment

Immediately after the injury, the injury site should be gently irrigated, wrapped in damp gauze, elevated, and have pressure applied to slow bleeding. Any obvious avulsion fractures should be stabilized and care should be taken to avoid jostling the patient. Perform neurological and neurovascular checks on the affected area. The patient should immediately be transported to the emergency room. If the skin or tissue is completely detached, it should be wrapped in damp gauze or a clean cloth, placed in a watertight bag, and then placed on ice to slow tissue degradation.

The primary treatment is surgery to perform an initial debridement, repair, and closure (if possible) of the wound. Skin grafts and further surgeries may be necessary depending on the severity of the injury. The patient may wear a wound vacuum at the site of injury for days or weeks to promote healing by wicking away exudate and increasing blood flow. If the skin is not salvageable, the patient may need to visit a wound care clinic regularly to slowly heal the wound from the inside out. If the wound simply won’t heal, then amputation at a later date is needed. Physical and occupational therapy can help to address mobility issues caused by the injury.

Wound Infections

Wound infections occur when an opening in the patient’s skin develops a bacterial or fungal infection. Left untreated, the infections can spread, eventually reaching the patient’s bones and bloodstream and becoming life-threatening, or cause the patient to need an amputation of the infected area. Infections that settle on an implant, such as a joint replacement or prosthetic heart valve, are extremely challenging to treat.

Assessment

Assess the site of the wound carefully. Look for any redness, swelling, heat, purulent drainage, or foul odor emanating from the wound. Monitor the patient’s vital signs closely and watch for any fever or chills that indicate a systemic infection. The patient’s wound should be cultured to determine which pathogen is causing the infection and to determine which medication is most effective at treating the infection. A CBC, lactic acid, and blood cultures will be drawn. An X-ray will help to show whether the patient has developed osteomyelitis. If the infection is severe, the patient may require pain relief as well.

Treatment

The treatment depends on the severity of the infection. Mild infections are often responsive to a single course of broad-spectrum antibiotics. More severe infections often require a prolonged course of antibiotics, up to six weeks. If this is the case, the patient will need to have a PICC line placed for extended-use intravenous access.

Some patients can be taught to administer IV antibiotics at home, but others will need to have home health care, go to an infusion center, or even be admitted to a skilled nursing facility. The patient may also need to undergo surgical treatment to debride the infected wound. In some cases, multiple irrigation and debridement procedures are needed. Depending on the location of the patient’s injury, they may have limited mobility and need to use a mobility aid and/or attend physical therapy and occupational therapy to rebuild their strength.

Injection Injuries

An injection injury occurs when a lesion in the skin develops after an injection. This injection can be intentional or accidental. Intentional injection examples include an IV start, intramuscular injection of medication, or subcutaneous injection of medication. The most common cause of accidental injections is grease guns, followed closely by paint guns.

Assessment

In some cases, the injection injury is immediately apparent, especially if it is due to a traumatic injection such as an accident with a grease gun or paint gun. There will be a traumatic puncture in the skin and redness, irritation, swelling, and pain surrounding the injection site. A reaction to a subcutaneous, intramuscular, or intravenous injection may not become apparent until hours or days later.

• In phlebitis, the vein in which the patient’s IV sits becomes irritated, causing a red streak to appear on the skin that follows the path of the vein under the patient’s skin.

• In extravasation, irritating medication leaks out of the vein and into the tissue surrounding the vein. This causes severe irritation, resulting in redness, skin breakdown, swelling, pain, and even tissue necrosis, evidenced by blackened tissue eventually appearing around the extravasation site and the formation of an open wound.

• An infected peripheral IV or central line site will appear red, swollen, warm, and painful. The patient may also develop systemic signs of infection, such as a fever or chills, which is more common with a central line infection due to its proximity to the heart and lungs.

Treatment

Any foreign bodies or chemical irritants should immediately be removed or irrigated to rinse the substance away. Sometimes this is a procedure that can be achieved with simple irrigation and forceps in the emergency room; at other times, it will require a surgical removal to be performed under anesthesia.

Any irritating medication that results in extravasation should be immediately stopped, and any remaining medication aspirated from the IV and the IV should be removed. Depending on the medication, hot or cold compresses can be applied, and the affected area should be elevated. Phentolamine and terbutaline can be used to treat vasopressor extravasation. Hyaluronidase can be used to treat amiodarone extravasation.

Lacerations

A laceration is a full-thickness cut in the skin that occurs due to trauma. This can be due to relatively minor trauma or a severe underlying injury with underlying soft tissue or bone damage. A laceration can be small (less than an inch) or large.

Assessment

Assess the injury site thoroughly. Note whether it was a clean cut with precise edges, or a macerated wound with uneven edges. Ask the patient about the circumstances under which the laceration occurred and ask them what caused the laceration. Note how heavily the laceration is bleeding and how deep it appears to be. Perform a neurovascular and neurological check. An X-ray may need to be performed to check for any underlying tissue or bone damage. If there has been profuse bleeding, the patient may need to have a CBC drawn to check their hemoglobin and hematocrit levels, especially if they are tachycardic or hypotensive.

Treatment

The treatment depends on the severity, cause, and shape of the injury. Pressure should be applied immediately to the wound with a clean cloth or sterile gauze. Small lacerations will often heal on their own, or can be closed with steri-strips to encourage the skin edges to come together.

If the laceration is severe, then sutures or staples will be needed to close the wound. Extremely large lacerations may require surgical closure. Antibiotics may be prescribed if the laceration is large or the object that caused the laceration was extremely dirty. The patient may require a Tdap vaccination to prevent tetanus if they are not up to date (administered in the last 10 years).

Penetrating Injuries

Penetrating injuries occur when an object penetrates the skin and into the underlying structures. Types of penetrating injuries include stab wounds, gunshot wounds, impalement injuries (often workplace-related), and wounds created by other sharp objects such as a shard of glass or stepping on a nail. The amount of damage that occurs depends on the penetrating object and the depth to which it penetrates. A perforating injury occurs when a penetrating injury passes all the way through the body or structure with an entrance and exit wound (like some gunshot wounds).

Assessment

Assess the area of injury. If the penetrating object is in place, then leave it in place and stabilize it as necessary until an X-ray or CT scan can be performed to see exactly what structures are affected. Objects such as a bullet can ricochet internally and cause more damage than is immediately apparent. Removing the penetrating object can worsen bleeding and cause more damage, especially if it gets caught on something.

Note any areas of bleeding. If the wound is bleeding, pressure should be applied with wound packing and/or direct pressure held. The patient’s vital signs should be monitored closely. Severe penetrating wounds can result in severe hemorrhages, something that liver and spleen lacerations are especially prone to doing due to the highly vascular nature of the organs. A CBC, CMP, and type and screen should all be drawn.

Treatment

Severe penetrating wounds will likely require immediate surgical repair to address internal damage and any areas of hemorrhage. Less severe wounds can be irrigated and sutured in the emergency department. Intravenous antibiotics will be administered to help prevent infections for severe wounds; oral antibiotics will suffice for minor injuries. If the patient experiences major hemorrhage, they may need packed red blood cells, fresh frozen plasma, cryoprecipitate, or platelets, as well as fluid resuscitation.

Wound Bleeding

Hemorrhages are severe bleeding that can be internal or external. Any wound can cause a hemorrhage if it hits a major vessel or artery. This bleeding can be life-threatening if it is not promptly treated. Blood-thinning medications and clotting disorders such as hemophilia and von Willebrand can significantly exacerbate an otherwise minor episode of bleeding.

Assessment

If the hemorrhage is external, the bleeding is almost always apparent. Immediately locate the source of the bleeding and assess the wound. Note whether the blood is bright red (arterial) or darker (venous), and whether there is any pulsation to the bleeding that would indicate the hemorrhage is coming from an artery. Evaluate the severity of the wound and what underlying structures (if any) are visible.

Internal bleeding can initially be more subtle. Symptoms of internal bleeding include steadily increasing abdominal or chest pain, increasing difficulty in breathing, abdominal tenderness, abdominal distension, and resonance or dullness on percussion. The Cullen sign is a ring of bruising around the belly button that indicates either an intraperitoneal or retroperitoneal hemorrhage. A CT scan will be needed to definitively diagnose internal bleeding. A CBC, CMP and** type and screen** will be drawn.

The patient will become tachycardic, hypotensive, and anxious as the hemorrhage continues. The classes of hemorrhage are as follows:

• Class 1—<15% total blood volume lost
  • Symptoms include anxiety and mild tachycardia.
• Class 2—15-30% total blood volume lost
  • Symptoms include moderate tachycardia, mild hypotension, and clammy skin.
• Class 3—30-40% total blood volume lost
  • Symptoms include severe tachycardia, significant hypotension, and altered mental status.
• Class 4—>40% total blood volume lost
  • Symptoms include severe hypovolemic shock, loss of consciousness, and multiple organ failure.

Treatment

The primary treatment for hemorrhage is to control the bleeding. If the bleeding is external, pack the wound firmly with clean gauze and apply a pressure dressing. Manual pressure may be held as well. A tourniquet can be applied if the injury occurs on one of the patient’s limbs. Internal bleeding needs to be surgically treated.

Some cases of internal bleeding are mild enough (usually a grade I or II laceration to an organ such as the liver or spleen) that the patient can be monitored in the hospital and placed on bedrest to avoid exacerbating the bleeding, and have serial hemoglobin levels drawn every 6-8 hours to watch for signs of worsening bleeding. If the hemorrhage occurs in a closed space such as the skull, it may need to be surgically drained to prevent brain damage due to increases in the patient’s intracranial pressure. Severe hemorrhages will require the patient to receive packed red blood cells, platelets, fresh frozen plasma, and cryoprecipitate, as well as fluid resuscitation with crystalloid fluids. Vitamin K can be used to reverse warfarin and lower the patient’s PT-INR if it’s elevated.