Management of lacerations in the emergency department

Metallic foreign body in the ulnar nerve in the Guyon's canal and Review of the Literature

The authors present a rare case of a 61-year-old patient with a metal foreign body inside the ulnar nerve in the Guyon's canal. After the surgical removal the motor function was not impaired. At 6-month follow up from the surgical removal, the patient showed a complete motor and sensory function.

Retrospective evaluation of 377 patients with penetrating foreign body injuries: a university hospital experience (a present case of missed sponge foreign body injury)

Background/aim

This study aimed to retrospectively analyse patients with foreign body (FB) injuries in our hospital and to present a patient with missed penetrating sponge FB injury.

Materials and methods

This study lasted 12 years (2008–2020) and reviewed all patients with FB injuries who were admitted to the emergency department (ED) of our hospital. Along with our overall results, we present a case with missed penetrating sponge FB injury in detail.

Results

Approximately 377 patients were included in the study (age: 28.3 ± 18.3 years, m/f: 229/148). The foot (n = 148, 39.3%) and the hand (n = 143, 37.9%) were the most frequently injured body parts. Regarding FB types, sewing needles (n = 140, 37.1%), metal pieces (n = 91, 24.1%), and glass (n = 80, 21.2%) were the most frequently observed objects. Most of the patients were injured at home, often by needles or glass. The injury-admission mean time was 7.38 ± 2.5 days. FBs were frequently removed in the ED (n = 176, 46.7%). Plain radiography is the first line in identifying FBs. Soft tissue infection was the most common complication. MRIs were much useful than USGs in detecting the missed penetrating sponge injury of the single patient in the study.

Conclusion

For diagnosis of FBs, besides recording the patient’s history, obtaining a two-sided radiogram is of great importance. For nonradiolucent or deeply located FBs, further clinical or radiological investigation must be considered to avoid complications. Although most of the FBs can be removed in the ED, patients may require hospitalisation and operation for FB removal, depending upon FB location and age.

Histopathological Comparison of 2-Octyl Cyanoacrylate and Primary Suturing for Tongue Lacerations

OBJECTIVE

To enable tongue incisions to be repaired more easily, rapidly, and practically, particularly in pediatric patients by using 2-octyl cyanoacrylate (OCA) tissue adhesive.

METHODS

A single linear incision was made on the midline dorsal part of the tongue. Twenty-four rats were randomly divided into the four groups: Group 1 (n = 6), OCA healing at day 5; group 2 (n = 6), OCA healing at day 21; group 3 (n = 6), Vicryl healing at day 5; group 4 (n = 6), Vicryl healing at day 21. In groups 1 and 2, OCA was applied to the incision site. The incisions of the rats in groups 3 and 4 were closed using Vicryl sutures. Histopathological examination was compared between and within the groups at day 5 and 21.

RESULTS

The operation duration was significantly shorter with OCA than with Vicryl sutures(P < 0.001). Regarding the histopathological results, there were no differences between group 1 and group 3 in epithelial regeneration, inflammation, fibroblastic activity, edema, presence of giant cells, fibrin deposition, ulceration, abscess formation, and granulation tissue. However, moderate infiltration of acute inflammatory cells was significantly more frequent in group 1 than in group 3. At day 5, the incidence of moderate foreign body residue was significantly higher in group 1 than in group 3. No difference was observed between group 2 and group 4 at day 21 (P > 0.05).

CONCLUSION

OCA is a practical, rapid, and effective method for repairing tongue lacerations. Although infiltration by inflammatory cells and foreign bodies increased in the early period, the long-term results of OCA were indistinguishable from those of suturing.

Retained wooden foreign body in groin in a child: A case report and review of literature

Wooden foreign body (WFB) injuries in children are common. They may report with acute presentation or be delayed as retained foreign body giving rise to complications. Cases with superficial skin penetration by these foreign bodies and acute presentation may be convenient to diagnose and remove. However, localising deeply impacted and chronically retained WFB is challenging, as they are usually not radiopaque and have a tendency to move deeper into the surrounding soft tissues with time. Foreign body retained for prolonged duration may present with either cellulitis, deep tissue infections, sinus, restriction of joint movements, necrotising fasciitis, osteomyelitis or tumour-like mass. We present an 8-year-old boy with discharging sinuses in the right iliac fossa and medial aspect of the right upper thigh, due to an impacted WFB for 3 months. Prompt radiological imaging and surgical removal helped him recover completely.

Making better wound management decisions

Clinicians make wound management decisions based on scientific research of varying quality as well as personal and observed habits, anecdotal evidence, and even misinterpreted data. This article examines some common traumatic wound management topics and discusses appropriate decision-making for wound management.

Primary Repair of a Complex Panfacial Fracture by Dog Bite

Facial fractures due to dog attacks have an unknown incidence rate. To date, only 41 cases of canine bite trauma in a pediatric patient, associated with facial fracture, have been reported in the literature. As major species of involving dogs are the American pitbull terrier and rottweiler. Due to the intense kinematics of this trauma, the treatment becomes complex. Thus, attention to the primary repair of such complex lesions ensures satisfactory results, which is the focus of this discussion. The purpose of this review was to analyze how different ways to approach this type of trauma in children for clarification or correct management. In addition, we address the treatment plan of a complex case of panfacial fracture by a canine bite in a 4-year-old patient. According to a review addressed, the main involved are orbit, nasal, and zygomatic. Antibiotic therapy is indicated for infected bite wounds and wounded considerations at risk of infection, with high complexity and when involving important structures such as bones, vessels, and joints. The state of tetanus immunization and the risk of rabies infection should be routinely addressed in the management of the bite wound.

A Pilot Study on the Repair of Contaminated Traumatic Wounds in the Emergency Department Using Sterile versus Non-Sterile Gloves

Background

Although the use of sterile gloves for minor and major surgical repairs is the current standard of care, use of non-sterile and clean gloves has been shown to be safe in certain procedures. In this study, we compared the infection rates of contaminated lacerations repaired with sterile versus non-sterile gloves.

Materials and methods

A prospective, randomised, two-centre pilot trial included patients that attended the emergency department with any type of visible contaminated soft tissue lacerations. The patients were selected according to convenience sampling technique and divided into two groups using random number table. Age, sex, and characteristics of the wound were assessed by a physician. According to that, the physician used sterile gloves or non-sterile, clean gloves for wound repair. Clinical data were analysed by chi-square test and paired-t test where appropriate. A p value =/< 0.05 was considered as statistically significant.

Results

Two hundred and twenty two recruited subjects with visible contaminated simple wounds were randomised to 2 groups. Males constituted 89.2% of the patients. The sites of lacerations were extremities in 50.5% of patients, head or neck in 48.4% of patients, and trunk in 1.1% of patients. Overall infection rate was 3.2%. The infection rates in the sterile gloves group and the clean gloves group were 2.02% and 4.6%, respectively (relative risk=2; odds ratio=2.3). Incidence of infection was not significantly different between two groups (p=0.322).

Conclusion

It seems that uses of clean gloves rather than sterile gloves do not increase the risk of infection in the repair of contaminated simple wounds in emergency department setting. (Hong Kong j. emerg.med. 2014;21:148-152)

Randomized, controlled trial of povidone-iodine to reduce simple traumatic wound infections in the emergency department

INTRODUCTION

Povidone Iodine (PVI) has been used to prevent wound infection for a long time, yet the merits and effectiveness of this agent in reducing the rates of infection in simple traumatic wounds have been debated. The aim of this study is determine the effect of PVI as skin disinfectant in preventing simple traumatic wound infection after repair in emergency departments.

METHODS

This study is a single-blind, randomized, controlled trial, conducted at the emergency departments of two university hospitals. In this trial, those collecting and analyzing data were unaware of the assigned treatment. Participants included ED patients with simple traumatic wounds, randomly assigned to either experiment or control groups. Wounds were similarly irrigated with normal saline in both groups. But the skin around the wounds of patients in the experiment group was cleansed by PVI solution. The patients were followed till their next ED visit for stitch removal. The presence or absence of wound infection was considered as the primary outcome and assessed by an ED physician.

RESULTS

In total, 444 patients were screened and included in the study. The patients were statistically similar according to their baseline characteristics. Men constituted 85% of the study participants. The highest numbers of reported wound sites belonged to head (30%), lower limbs (24%) and upper limbs (19%) accordingly. The rates of infections in the experiment and control groups were similar (p=0.231) but a significant association was observed between the rate of infections and wound location. Lower limbs (OR=9.23, p<0.0001) and upper limbs (OR=5.47, p=0.011) indicated the highest risks of wound infections among other locations.

CONCLUSION

Our study showed that using PVI in the management of traumatic wounds did not reduced rate of infections.

Animal Inflicted Maxillofacial Injuries: Treatment Modalities and Our Experience

INTRODUCTION

Animal inflicted injuries to the face and neck are becoming much more common as people lavish affection on pets. Injuries caused by animal attacks to the face can cause complex injuries to soft and hard tissues, presented as perforations, lacerations, crushes, avulsion or fractures. An uncountable number of bacteria and virus can be found in such injuries, with a potential pathological effect to humans, regarding infections. Although the infection rate is low due to excellent blood supply to face, the injuries have disfiguring effect with possible psychological repercussion to the patients. The treatment of animal inflicted injuries must address the soft tissue defect, neurovascular injuries, and bone injuries as well as prevention of post treatment infection. Primary wound repair is the treatment of choice for most clinically uninfected bite wound where as delayed closure should be reserved for wounds at high risk of infection or already infected wounds and tissue defect may require local flap or micro-vascular re-implantations.

MATERIAL AND METHODS

In this article, we have elicited up to date considerations regarding the management of animal inflicted injuries to the face based on literature search and exemplified by multiple case reports.

CONCLUSION

For bite injuries on face, immediate primary wound repair after meticulous wound debridement and irrigation with sufficient volume added by antibiotic prophylaxis gives good cosmetic results with minimum risk of infection. Depending upon type of attack and age of victims, psychiatric or social counseling may also be required.

Negative pressure wound therapy for serious dog bites of extremities: a prospective randomized trial

OBJECTIVES

The objectives were to investigate the emergency treatment of serious dog bite lacerations on limbs and to identify whether negative pressure wound therapy (NPWT) was beneficial in these instances.

METHODS

A total of 580 cases with serious limb lacerations due to dog bites were randomly divided into 2 groups. After thorough debridement, the limb lacerations of group A (n = 329) were left open. The remaining cases (n = 251) were randomly divided into 2 subgroups, group B and group C, which were treated with 125 and 75 mm Hg of continuous negative pressure, respectively. Antibiotics were only used in cases where there were systemic signs of wound infection, and were not given prophylactically. The infection rate, infection time, and healing time were analyzed.

RESULTS

The wound infection rates of groups A, B, and C were 9.1%, 4.1%, and 3.9%, respectively. The infection times of the 3 groups were 26.3 ± 11.6, 159.8 ± 13.4, and 166.4 ± 16.2 hours, respectively. The recovery times of the infection patients in the 3 groups were 19.2 ± 4.6, 13.2 ± 2.1, and 12.7 ± 2.3 days, respectively, and in the noninfection patients, the recovery times were 15.6 ± 2.7, 10.1 ± 2.3, and 10.5 ± 1.9 days, respectively. In groups B (-125 mm Hg) and C (-75 mm Hg), the infection rate, infection time, and healing time showed no significant differences.

CONCLUSION

Patients with serious dog bite laceration on limbs could benefit from NPWT. Compared with the traditional treatment of leaving the wounds open, NPWT reduced the infection rate and shortened recovery time. When NPWT was performed, low negative pressure (-75 mm Hg) had the same positive effects as high pressure (-125 mm Hg). Prophylactic antibiotics administration is not recommended for treating this kind of laceration.

LEVEL OF EVIDENCE

Therapeutic/care management, level II.

The primary closure approach of dog bite injuries of the nose

The nose holds an outstanding position on the face, acquiring great importance within the context of facial aesthetics. Because of the functional, psychological, and social aspects of trauma in a society increasingly demanding about aesthetics, treatment institution must reduce, as accurate as possible, the sequelae that hinder social integration. This clinical report relates an immediate nasal reconstruction of a complex animal bite wound. A 7-year-old patient was victim of a dog bite with avulsion of the left nasal ala and part of the ipsilateral nasal tip. The treatment was immediate nasal reconstruction with auricular composite graft. After 1 year of follow-up, the shape of nasal ala was stable, and the color was consistent with the surrounding tissue. The 2 nasal sides exhibited satisfactory symmetry when evaluated. It can be concluded that the composite graft derived from the auricular helix is a safe option for reconstruction of nasal ala defects with compromised margins in pediatric patients when conditions of reimplantation do not exist.

Thorough debridement and immediate primary wound closure for animal bite injuries of the upper limbs

PURPOSE

Animal bite injuries are often encountered in daily practice. In particular, these injuries of the upper limbs can result in severe functional impairment. We have performed early debridement of contaminated tissue and primary closure for these injuries.

METHODS

The subjects consisted of 15 patients (6 males and 9 females) aged 1-91 years (mean 53.6 years) who visited our hospital due to animal bite injuries (dog in 9 patients, cat in 6). The bite site was the forearm in 5 patients and the hand in 10. In the operating room, contaminated tissue was removed, and primary wound closure was performed after irrigation.

RESULTS

The bite penetrated to the muscle layer in 6 patients, tendon sheath in 5, joint in 1, bone in 1, and involved only the subcutaneous tissue in 3 patients. The mean period until the completion of wound treatment was 19.8 ± 8.4 days. As complications, numbness of finger, metaphalangeal joint contracture and superficial radial nerve injury were observed in each one case. In a patient with bite injury of the palmar and dorsal sides of the thumb reaching the bone, additional debridement was necessary. At the final observation, the visual analog scale was 1.2 ± 1.4, and the Quick Disabilities of the Arm, Shoulder, and Hand score was 9.7 ± 12.2.

CONCLUSIONS

Debridement to achieve wound closure is indispensable in patients with animal bite injuries of the upper limbs. The results of our study suggest that thorough debridement allows primary closure, even for animal bite injuries.

Are patients willing to remove, and capable of removing, their own nonabsorbable sutures?

Objectives:

Providing patients with instructions and equipment regarding self-removal of nonabsorbable sutures could represent a new efficiency in emergency department (ED) practice. The primary outcome was to compare the proportion of patients successfully removing their own sutures when provided with suture removal instructions and equipment versus the standard advice and follow-up care. Secondary outcomes included complication rates, number of physician visits, and patient comfort level.

Methods:

This prospective, controlled, single-blinded, pseudorandomized trial enrolled consecutive ED patients who met the eligibility criteria (age &gt; 19 years, simple lacerations, nonabsorbable sutures, immunocompetent). The study group was provided with wound care instructions, a suture removal kit, and instructions regarding suture self-removal. The control group received wound care instructions alone. Outcomes were assessed by telephone contact at least 14 days after suturing using a standardized questionnaire.

Results:

Overall, 183 patients were enrolled (93 in the intervention group; 90 in the control group). Significantly more patients performed suture self-removal in the intervention group (91.5%; 95% CI 85.4–97.5) compared to the control group (62.8%; 95% CI 52.1–73.6) (p&lt; 0.001). Patients visited their physician less often in the intervention group (9.8%; 95% CI 3.3–16.2) compared to the control group (34.6%; 95% CI 24.1–45.2%) (p&lt; 0.001). Complication rates were similar in both groups.

Conclusion:

Most patients are willing to remove, and capable of removing, their own sutures. Providing appropriate suture removal instructions and equipment to patients with simple lacerations in the ED appears to be both safe and acceptable.

Detecting foreign bodies in a head laceration

Open wounds represent a potential area of medicolegal risk if foreign bodies are not identified prior to wound closure. The importance of imaging of lacerations was underscored by a recent case where a 20-year-old male collided with a friend's mouth on a trampoline sustaining a simple, superficial scalp laceration. The wound was evaluated in typical fashion including irrigation and local exploration and was prepared for closure. The friend was then evaluated and noted to have multiple extensive dental fractures. An increased index of suspicion generated further evaluation of the first patient's wound. Plain radiography obtained of the first patient's skull was noted to have bony foreign bodies consistent with teeth, which were then removed after further exploration. Superficial wounds are common and complications arising from retained foreign bodies are a potential source of substantial morbidity and consequently medical litigation. This case serves as a reminder to be vigilant and maintain a high index of suspicion regarding the potential for foreign body.

Ultrasound-guided needle localization to aid foreign body removal in pediatric patients

Patients with podiatric foreign body injury commonly present to the emergency department. Often, the foreign object cannot be easily located or removed, and radiographs are frequently obtained to aid in localization. In cases requiring tissue dissection to remove the foreign bodies, accurate localization is required for safe removal of small and difficult to visualize bodies. We present 2 pediatric cases in which an ultrasound-guided needle localization technique was used to facilitate successful removal of small, difficult to visualize foreign bodies from the plantar foot. Ultrasound-guided needle localization reduced the required incision length and depth and helped to minimize the risk of damage to surrounding tissue.

Maxillofacial injuries due to animal bites

INTRODUCTION

Animal bites are a significant public health problem, with the majority of bites coming from dogs, cats and humans. These may present as punctures, abrasions, tears, or avulsions. The force and relative bluntness of the teeth also increases the possibility of a crush injury with devitalized tissue .The clinical presentation and appropriate treatment of infected bite wounds vary according to the animal and causative organisms. These wounds have always been considered complex injuries contaminated with a unique polymicrobial inoculum.

MATERIALS

This article reviews animal bite wound incidence, bacteriology, risk factors for complications, evaluation components, recommended treatment and prevention based on advanced PUBMED search of the English language literature from the years 1970 to present.

CONCLUSION

As the bite wounds are frequently located on the face, an oral and maxillofacial surgeon needs to be familiar with the treatment of animal bites, pitfalls in management and to educate patients on ways to avoid future bite injuries. The management of animal bites is an evidence poor area and most recommendations are based on small case series, microbiological data and expert opinion. The main controversies include whether wounds should or should not undergo primary closure and the use of prophylactic antimicrobials.

Emergency treatment on facial laceration of dog bite wounds with immediate primary closure: a prospective randomized trial study

BACKGROUND

To investigate the emergency treatment on facial laceration of dog bite wounds and identify whether immediate primary closure is feasible.

METHODS

Six hundred cases with facial laceration attacked by dog were divided into two groups randomly and evenly. After thorough debridement, the facial lacerations of group A were left open, while the lacerations of group B were undertaken immediate primary closure. Antibiotics use was administrated only after wound infected, not prophylactically given. The infection rate, infection time and healing time were analyzed.

RESULTS

The infection rate of group A and B was 8.3% and 6.3% respectively (P>0.05); the infection time was 26.3 ± 11.6h and 24.9 ± 13.8h respectively (P>0.05), the healing time was 9.12 ± 1.30 d and 6.57 ± 0.49 d respectively (P<0.05) in taintless cases, 14.24 ± 2.63 d and 10.65 ± 1.69 d respectively (P<0.05) in infected cases.Compared with group A, there was no evident tendency in increasing infection rate (8.3% in group A and 6.3% in group B respectively) and infection period (26.3 ± 11.6h in group A and 24.9 ± 13.8h in group B respectively) in group B. Meanwhile, in group B, the wound healing time was shorter than group A statistically in both taintless cases (9.12 ± 1.30 d in group A and 6.57 ± 0.49 d in group B respectively) and infected cases (14.24 ± 2.63 d in group A and 10.65 ± 1.69 d in group B respectively).

CONCLUSION

The facial laceration of dog bite wounds should be primary closed immediately after formal and thoroughly debridement. And the primary closure would shorten the healing time of the dog bite wounds without increasing the rate and period of infection. There is no potentiality of increasing infection incidence and infection speed, compared immediate primary closure with the wounds left open. On the contrary, primary closure the wounds can promote its primary healing. Prophylactic antibiotics administration was not recommended. and the important facial organ or tissue injuries should be secondary reconditioned.

The importance of soft tissue examination in post-traumatic decision-making: a case report

Dental and facial traumas involving teeth and supporting tissues are common sports-related injuries. In this case report treatment of a 23-year-old student who had been elbowed by an opponent player during a basketball game, which caused oblique fractures on both maxillary incisor teeth is presented. The patient presented 17 days following trauma having completed full recovery of soft tissues. A fragment of upper incisor tooth had been embedded in lower lip at the time of trauma, which was covered by healing tissues. At the 1 month control the patient complained of a hard structure in his lower lip. The elusive broken fragment was revealed by a radiograph and then removed surgically. This case report is a good example of the importance of the training of general dentists about sports-related traumatic injuries as well as emphasising the importance of the use of mouthguards during contact sports.

Is there a relationship between wound infections and laceration closure times?

Background

Lacerations account for a large number of ED visits. Is there a “golden period” beyond which lacerations should not be repaired primarily? What type of relationship exists between time of repair and wound infection rates? Is it linear or exponential? Currently, the influence of laceration age on the risk of infection in simple lacerations repaired is not clearly defined. We conducted this study to determine the influence of time of primary wound closure on the infection rate.

Methods

This is a prospective observational study of patients who presented to the Emergency Department (ED) with a laceration requiring closure from April 2009 to November 2010. The wound closure time was defined as the time interval from when the patient reported laceration occurred until the time of the start of the wound repair procedure. Univariate analysis was performed to determine the factors predictive of infection. A non-parametric Wilcoxon rank-sum test was performed to compare the median differences of time of laceration repair. Chi-square (Fisher's exact) tests were performed to test for infection differences with regard to gender, race, location of laceration, mechanism of injury, co-morbidities, type of anesthesia and type of suture material used.

Results

Over the study period, 297 participants met the inclusion criteria and were followed. Of the included participants, 224 (75.4%) were male and 73 (24.6%) were female. Ten patients (3.4%) developed a wound infection. Of these infections, five occurred on hands, four on extremities (not hands) and one on the face. One of these patients was African American, seven were Hispanic and two were Caucasian (p = 0.0005). Median wound closure time in the infection group was 867 min and in the non-infection group 330 min (p = 0.03).

Conclusions

Without controlling various confounding factors, the median wound closure time for the lacerations in the wound infection group was statistically significantly longer than in the non-infection group.

Unusual presentation of cactus spines in the flank of an elderly man: a case report

INTRODUCTION

Splinters and spines of plant matter are common foreign bodies in skin wounds of the extremities, and often present embedded in the dermis or subcutaneous tissue. Vegetative foreign bodies are highly inflammatory and, if not completely removed, can cause infection, toxic reactions, or granuloma formation. Older patients are at increased risk for infection from untreated plant foreign bodies. The most common error in plant splinter and spine management is failure to detect their presence.

CASE PRESENTATION

Here we report a case of cactus spines in an 84-year-old Caucasian man presenting on the right flank as multiple, red papules with spiny extensions. This presentation was unusual both in location and the spinous character of the lesions, and only after punch biopsy analysis was a diagnosis of cactus matter spines made.

CONCLUSIONS

Our patient presented with an unusual case of cactus spines that required histopathology for identification. Skin lesions with neglected foreign bodies are a common cause of malpractice claims. If not removed, foreign bodies of the skin, particularly in elderly individuals, can result in inflammatory and infectious sequela. This report underscores the importance of thoroughly evaluating penetrating skin lesions for the presence of foreign bodies, such as splinters and spines.

Therapeutic endoscopy for acute upper gastrointestinal bleeding

Endoscopy is the primary diagnostic and therapeutic tool for upper gastrointestinal bleeding (UGIB). The performance of endoscopic therapy depends on findings of stigmata of recent hemorrhage (SRH). For peptic ulcer disease-the most common etiology of UGIB-endoscopic therapy is indicated for findings of major SRH, such as active bleeding, oozing, or the presence of a nonbleeding visible vessel, but not indicated for minor SRH, such as a pigmented flat spot or a simple ulcer with a homogeneous clean base. Endoscopic therapies include injection, ablation, and mechanical therapy. Monotherapy reduces the risk of rebleeding in patients with peptic ulcer disease with major SRH to about 20%. Combination therapy, especially injection followed by either ablation or mechanical therapy, is generally recommended to further reduce the risk of rebleeding to about 10%. Endoscopic dual hemostasis by an experienced endoscopist reduces the risk of rebleeding, the need for surgery, the number of blood transfusions required, and the length of hospital stay. This Review article comprehensively analyzes the principles, indications, instrumentation, techniques, and efficacy of endoscopic hemostasis.

High-risk chief complaints III: abdomen and extremities

Abdominal and extremity complaints are a frequent reason for presentation to the emergency department. Although these are common complaints, several abdominal and extremity disease entities may be missed or may be subject to delayed diagnosis. This article provides an overview of the diagnosis and management of several high-risk abdominal and extremity complaints, including appendicitis, abdominal aortic aneurysm, mesenteric ischemia, bowel obstruction, retained foreign body, hand and finger lacerations, fractures, and compartment syndrome. Each section focuses primarily on the pitfalls in diagnosis by highlighting the limitations of history, physical examination findings, and diagnostic testing and provides specific risk management strategies.

Use of prophylactic antibiotics in preventing infection of traumatic injuries

In managing traumatic wounds, the primary goal is to achieve rapid healing with optimal functional and esthetic results. This is best accomplished by providing an environment that prevents infection of the wound during healing. Despite good wound care, some infections still occur. Accordingly, some investigators argue that prophylactic antibiotics have an important role in the management of certain types of wounds. This article reviews the basis of antibiotic use in preventing wound infection in general and its use in oral and facial wounds in particular.

Management of facial bite wounds

Bite wounds are especially prone to infectious complications, both local and systemic. In bite wounds to the face, such complications can create more difficulties than the initial tissue damage itself for the task of restoring an esthetic appearance. Management should aim to neutralize this potential for infection and provide an infection-free environment for wound healing. Wound cleansing followed by primary closure is the treatment of choice, and the use of prophylactic antibiotics may further decrease the risk of infection. Delay in presentation beyond 24 hours is not necessarily a contraindication to immediate repair, but excessive crushing of the tissues or extensive edema usually dictates a more conservative approach, such as delayed closure.

A review of the epidemiology, pathogenesis and management of tetanus

Tetanus remains an important disease worldwide. In the United Kingdom, the elderly and intravenous drug users are at particular risk of acquiring clinical tetanus. Tetanus is associated with a high morbidity and mortality. Once the diagnosis of tetanus is suspected, intensive management is necessary. In this article we review the history, epidemiology, microbiology, clinical features, mode of transmission, pathogenesis, differential diagnosis, management, complications and prevention of this life threatening disease.

Closure techniques

There are many techniques available for the closure of traumatic wounds in emergency departments. Each method has its own unique benefits and limitations that must be considered in each case individually. The best technique provides durability, simplicity, excellent cosmetic outcome, and overall patient satisfaction. Unfortunately, at this time no single method is superior for all situations. Emergency physicians must be familiar with multiple techniques to provide the best outcomes for their patients.

Principles of Basic Wound Evaluation and Management in the Emergency Department

The primary objectives of basic wound management center around promoting optimal wound healing and cosmesis. These objectives may be achieved through the systematic assessment, preparation, and repair of the laceration supplemented with appropriate patient care instructions. The meticulous and methodical management of traumatic wounds described in this article will assist the emergency physician in decreasing overall complication rates and help improve patient satisfaction.

Reducing Risk in Emergency Department Wound Management

Although substantial dollar amounts are not involved, wound-care litigation constitutes a significant number of lawsuits to emergency medicine physicians, resulting in an increased drain on the physician's time and exposing the physician to all the psychosocial effects involved in the medicolegal process. The procedures outlined in this article-paying attention to wound-care principles, involving patients in the medical decision-making process, and ensuring appropriate medical follow-up-can, it is hoped, reduce the incidence of medical claims.

Clinical aspects of full-thickness wound healing

Optimal management of full-thickness wounds requires a thorough knowledge of wound-healing principles and practices. In the absence of underlying disease, almost every full-thickness wound will heal with minimal intervention; however, the process can be enhanced by judicious wound management. The first clinical decision to be made is whether to repair the wound or to allow it to heal by second intention. This decision is guided by a host of objective and subjective factors. Reconstruction options include primary closure, flaps, and grafts. Materials to aid reconstruction, including the introduction of tissue adhesives, continue to evolve. Both primary and secondary intention wounds are aided by occlusive dressings and adjutants. A plethora of wound-healing adjuncts have been developed to aid wound healing in diseased states, and a working knowledge of their use is beneficial in managing all full-thickness wounds.

Use of 2-Octyl Cyanoacrylate for the Repair of a Fractured Molar Tooth

Odontalgia in association with an acutely fractured tooth is a frequent reason for emergency department presentation. We describe the case of a patient who presented with a painful fractured molar tooth and was treated with topical application of 2-octyl cyanoacrylate tissue adhesive, resulting in prompt relief of her discomfort and a good temporary functional and cosmetic outcome. This product may prove useful in treating similar dental emergencies when access to emergency dental care is unavailable.

Facial bite wounds: management update

Bite wounds are frequently located on the face; injuries inflicted by dogs are most common, especially in children. Bacteriology of infected dog and cat bite wounds includes Pasteurella multocida, Staphylococcus aureus, viridans streptococci, Capnocytophaga canimorsus, and oral anaerobes. Infected human bites yield a similar spectrum of bacteria except for Pasteurellae and C. canimorsus; instead human bites are frequently complicated by Eikenella corrodens. Antibiotic therapy against these bacteria is indicated both for infected bite wounds and fresh wounds considered at risk for infection. Amoxicillin-clavulanate (and other combinations of extended-spectrum penicillins with beta-lactamase inhibitors) and moxifloxacin offer the best in vitro coverage of the pathogenic flora. Initial wound management consisting in irrigation and debridement is at least equally important with antibiotics for prevention of infection. The need for prophylaxis against systemic infectious complications, particularly tetanus, should also be evaluated. Primary surgical repair is the treatment of choice for most clinically uninfected facial bite wounds, whereas delayed closure should be reserved for certain high risk or already infected wounds. Avulsive injuries with significant tissue loss represent the most difficult cases for definitive management and are also those most likely to require hospitalization.