martes, 11 de noviembre de 2008

Current Management of Acute Cutaneous Wounds

I am critically appraising a review article concerning the state of the art of the management of acute cutaneous wounds, published in the New England Journal of Medicine in September 2008: N Engl J Med 2008; 359:1037-46

This includes general principles of care, which applies to all types of wounds, and more tailored care, which depends on the type of wound we’re dealing with. Acute cutaneous wounds can be classified as abrasions, lacerations (skin tears, plantar cutaneous wounds, mammalian bites and subungual hematomas) and burns (and in particular chemical burns and frostbite).

I will focus my review on what can be done in Primary Care to either treat the patient or to stabilise the patient until secondary or tertiary care is available.

General principles of care includes prevention of infection and optimising the healing of the wound. The latter can be achieved by ensuring a moist environment for the wound, using either a topical antimicrobial agent or an occlusive dressing.

The management of abrasions includes irrigation and removal of foreign bodies. One particular situation is the post-traumatic tattoing (abnormal skin pigmentation due to the absorption of foreign particles) following injuries from explosions of fireworks and “road rash” (following contact wth a surface containing asphalt, tar or dirt, such as in a motorcyle accident, for instance).

Lacerations can be classified as skin tears, plantar puncture wounds, mammalian bites and subungual hematomas. Skin tears are common in the primary care population, since they occur often in patients on long term steroid therapy and among the elderly. The skin tears with no tissue loss can be managed with the use of surgical tape and a non-adherent dressing. Skin tears with partial or complete tissue loss can be managed with the use of absorbent dressing (hydrogel, hydrocolloid, etc), which are normally available in primary health care centres.

Mammalian bites (dog, cat, human) require high pressure irrigation followed by closure, up to 12h after

injury, although puncture wounds and scratches should be left to heal by secondary intention, and thus covered with a topical antimicrobial agent and an absorbent dressing. Bites located over the metacarpophalangeal joints (MCP) are more susceptible to infection and should also be treated with systemic antibiotics. Human bites located over the MCP joints should be referred to an expert.

Subungual hematomas may require minor surgery manouvres such as nail removal and nail trephination using a handheld portable cautery, which most Primary Care physicians in Portugal are not skilled to carry them out, so they should probably be referred.

Burns can be classified, in terms of severity, according to the extension of body lenghth affected, as minor, moderate, major burns. For practical purposes, it is more useful to classify them as first degree, superficial second degree, deep second degree and third degree. Primary Care Physicians are more likely to see first degree and superficial second degree. Deep second degree and third degree should be referred to burn specialists. It is important to cool all burns with cold tap water (15º to 25º C) within 30 minutes after the incident until the pain is controlled, in order to minimise pain, the depth and the extent of the injury, need for surgical excision of the wound, scarring and mortality. Doctors must not apply ice or ice water because it may increase tissue injury.

In terms of local therapy, doctors can apply topical NSAID or aloe vera to reduce the pain in first degree burns, and a topical antimicrobial agent or an absoptive occlusive dressing in superficial second degree burns.

The approach to chemical burns consists simply of an abundant water lavage started at the scene, and the removal of all particles. Injuries from elemental metals (lithium, sodium, magnesium, and potassium) and from hydrofluoric acid entail a more complex approach and should be referred.

The treatment of frostbite includes immediate rewarming during 20 minutes in water at a temperature of 40 to 42º C, and opioids should be used to control the pain. The injured area should then be splinted and elevated, and analgesia should be continued with NSAID’s. Remember that it may be necessary to subsequently refer patients with frostbite injuries to secondary care.

Family Medicine residents should be aware of the general principles underlying the management of acute cutaneous wounds because it is a highly prevalent reason for seeking medical care, and it is not very well covered during the undergraduate years. In Portugal, car accidents, forest fires, professional hazards and domestic accidents have led to thousands of victims with acute cutaneous wounds. Residents, particularly those based in rural areas, are likely to encounter patients with active acute cutaneous wounds or with a history of previous acute cutaneous wounds in either the primary health centre or when working in emergency departments of hospitals. Frostbite injuries are less common in Southern European countries like Spain and Portugal, but may tend to become more common as more and more people go on skiing holidays.

It is important to be familiar with the management of the less serious wounds, since those can be approached with simple practical measures in the primary care setting, with the precious help of the nursing staff, who is normally better trained in applying and dealing with dressings.

It is also important to know when to refer a patient to secondary or tertiary care, specially in the case of burns.

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