Wounds, open trauma
Open trauma wounds (abrasions, avulsions, crush wounds, lacerations, missile injuries, and punctures) are injuries that commonly result from home, work, or motor vehicle accidents and from acts of violence.
Signs and symptoms
In all open wounds, assess the extent of injury, vital signs, level of consciousness (LOC), obvious skeletal damage, local neurologic deficits, and general patient condition. Obtain an accurate history of the injury from the patient or witnesses, including such details as the mechanism and time of injury and any treatment already provided. If the injury involved a weapon, notify the police.
Also assess for peripheral nerve damage — a common complication in lacerations and other open trauma wounds, as well as for fractures and dislocations. Signs of peripheral nerve damage vary with location as follows:
radial nerve—weak forearm dorsiflexion, inability to extend thumb in a hitchhiker’s sign
median nerve—numbness in tip of index finger; inability to place forearm in prone position; weak forearm, thumb, and index finger flexion
ulnar nerve—numbness in tip of little finger, clawing of hand
peroneal nerve—footdrop, inability to extend the foot or big toe
sciatic and tibial nerves—paralysis of ankles and toes, footdrop, weakness in leg, numbness in sole.
Most open wounds require emergency treatment. In those with suspected nerve involvement, however, electromyography, nerve conduction, and electrical stimulation tests can provide more detailed information about possible peripheral nerve damage.
Diagnosis
A thorough physical examination of the patient will reveal traumatic wounds. They may be seen during the primary and secondary assessment of the patient.
Treatment
If hemorrhage occurs, stop bleeding by applying direct pressure on the wound and, if necessary, on arterial pressure points. If the wound is on an extremity, elevate it if possible. Don’t apply a tourniquet except in a life-threatening hemorrhage. If you must do so, be aware that resulting lack of perfusion to tissue could require limb amputation. (For a description of types of wounds and specific management, see Managing open trauma wounds, pages 911 to 914.)
Special considerations
Frequently assess vital signs in patients with major wounds. Be alert for a 20 mm Hg drop in blood pressure and a 20 beat increase in pulse (compare the patient’s blood pressure and pulse taken when he’s sitting with those taken when he’s lying down), increased respiratory rate, decreasing LOC, thirst, and cool, clammy skin—all indicate blood loss and hypovolemic shock.
Administer oxygen as ordered.
Send blood samples to the laboratory for type and crossmatch, complete blood count (including hematocrit and hemoglobin levels), and prothrombin and partial thromboplastin times.
Prepare the patient for surgery if needed.
As much as possible, tell the patient about the procedures that he’ll undergo (even if he appears unconscious) and provide reassurance.
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