CHAPTER KEY WORDS
An 18-year-old male high school soccer player collides with another player while going for the ball. The other player’s spike strikes the first player’s anterior medial tibia region. He sustains obvious bruising and a laceration. The player asks the athletic trainer to butterfly it closed so he can continue to play the game.
The athletic trainer determines that due to the depth and appearance of the wound, it would not be amenable to a butterfly bandage. It has deep portions and needs appropriate wound care that cannot be provided on site. The athletic trainer appropriately applies a dry dressing and refers the patient to the local emergency department for definitive care. In the emergency department the patient has the wound cleansed with Hibiclens (chlorhexidine gluconate) solution. The wound bed is then anesthetized with lidocaine with epinephrine. The dermal avulsion is pulled back, and the wound is copiously irrigated. There is no evidence of tendon or ligament injury or exposed bone. The avulsed tissue is approximated as best as possible. The deep layers are approximated with absorbable suture, then the superficial layers are closed using a running nylon suture. The wound is dressed with antibiotic ointment, a nonadherent dressing, gauze, and kling. Daily dressing changes are performed. On day 10, the sutures are removed without complication.
Patients can sustain injuries to their skin and underlying structures from direct and/or indirect injury, as well as blunt and/or penetrating trauma. This chapter will focus on basic anatomy of the integumentary system and its underlying components, common injuries, and life-threatening injuries. The basic principles of wound care will be discussed, and control of hemorrhage will be explained.
The skin is the largest organ of the human body and comprises the integumentary system, which protects the underlying muscles, bones, ligaments, and internal organs. The skin is composed of 3 layers: the epidermis, dermis, and hypodermis (Figure 9-1).
The epidermis is the outermost layer, which forms a protective barrier over the body surface. The epidermis helps regulate body temperature and contains no blood vessels.
The dermis is the layer underneath the epidermis and consists of connective tissue that cushions the body from stress and strain. The dermis is tightly connected to the epidermis and contains nerve endings, blood vessels, lymphatic vessels, hair follicles, and exocrine glands. The dermis is divided into 2 regions. The papillary region comprises areolar connective tissue. The papillae extend toward the epidermis and provide the dermis with a rough surface that integrates with the epidermis, which strengthens the connections between the two layers of skin. The reticular region lies deep in the papillary region and contains dense irregular connective tissue that contains collagen, elastin, and reticular fibers.
The hypodermis is the subcutaneous tissue that lies below the dermis and consists of adipose tissue and elastin. The hypodermis attaches the dermis to the underlying muscle and bone and contains nerves and blood vessels.
Trauma to the Skin
Skin injuries can be sustained through direct or indirect contact and can be caused by both penetrating and non-penetrating sources. Common traumatic injuries include contusions, abrasions, penetrating injuries, burns, and lacerations.1
Contusions are regions of skin in which the capillaries have been ruptured. Contusions will go through evolutionary stages until they resolve. They can be painful, and, depending on the nature of the injury, there could be concern for underlying trauma. Treatment for isolated contusions includes rest, ice, and elevation of the extremity. They can take days to weeks to resolve. Contusions should be monitored to ensure they are resolving and that a hematoma is not expanding under the skin (Figure 9-2).
Abrasions are wounds caused by superficial damage to the epidermis. Abrasions involve contact with an object or surface and can be superficial or deep. Superficial abrasions heal without scarring, whereas deep abrasions can form scar tissue. Abrasions usually bleed at the time of injury and can be painful. Treatment for abrasions includes washing the affected area with soap and water and removing any debris from the wound bed. They should be covered with antibiotic ointment and a nonadherent dressing and then wrapped with gauze and Curlex (American Excelsior Company). This should be done at least once or twice per day, and the area should be monitored for signs of infection (Figure 9-3).
Burns are common household and industrial injuries. They can be caused by liquids, chemicals, fire, electricity, inhalation, and ultraviolet radiation. Burns are characterized based on severity of damage to the skin and on depth. The current classification system references superficial (first-degree), partial-thickness (second-degree), and full-thickness (third-degree) burns. Burns to the face, hands, and genitals are considered critical burns. Any partial- or full-thickness burn in a child with greater than 10% body surface area affected or an adult with greater than 15% to 20% of the body’s body surface area affected is considered significant and should be evaluated at a burn/trauma center.
Sunburn is an inflammatory response that causes damage to DNA in the skin cells as a result of overexposure to ultraviolet radiation. Typically, the skin becomes reddened, hot, with or without mild swelling, and can be associated with pain and fatigue. Certain populations, including children and the elderly, can be especially susceptible, and preventative measures, such as using sunscreen, are helpful. Sunburn is a superficial burn that can be treated with moisturizing cream.
Superficial (First-Degree) Burns
Superficial burns usually affect the epidermis. The site of injury appears red, painful, and dry, without blister formation. Superficial burns usually resolve with conservative treatment, and long-term tissue damage is rare (Figure 9-4).
Partial-Thickness (Second-Degree) Burns
Partial-thickness burns involve the epidermis and part of the dermis. The site of injury appears red, swollen, and painful, with blister formation. Partial-thickness burns can be further classified into superficial and deep partial-thickness burns, depending on the degree of the dermis involved. Fluid will build up under the skin and separate the epidermis from the dermis. When the blister ruptures, it will expose the dermis, and, depending on the total body surface area involved, significant water loss and loss of thermoregulation can occur. Caution must be taken when managing partial-thickness burns, as they can evolve into full-thickness burns despite treatment. Partial-thickness burns require treatment by a certified burn/trauma physician and, depending on the percent body surface area and depth, may require skin grafting. Smaller partial-thickness burns will heal by contracting scarring. These burns, if untreated, can lead to hypothermia, infection, sepsis, and death (Figure 9-5).
Full-Thickness (Third-Degree) Burns
Full thickness burns involve the epidermis and the dermis. They can also involve the underlying muscle, tendon, and bone. The site of injury is white and leathery or can appear charred. These burns are insensate, as the nerve endings are damaged. Full-thickness burns require treatment by a certified burn/trauma physician and, depending on the percent body surface area, will require skin grafting. Smaller full-thickness burns will heal by contracting scarring. These burns, if untreated, can lead to hypothermia, infection, sepsis, and death (Figure 9-6).
Treatment of Burns
Treatment of burns involves stopping the burning process, which can be accomplished by removing the patient from the environment or the process from the patient. However, ensure your safety first. All partial- and full-thickness burns should be covered with a dry dressing, and the patient should be transported to a facility capable of handling burn patients. Prior to handling the burn injuries, the patient should be assessed for any other threats to life.
Lacerations are common injuries that involve contact with an object or surface that causes damage through the epidermis and dermis, with a superficial or deep break in the skin. Lacerations can involve the fatty tissue below the hypodermis, tendons, ligaments, and muscle and can expose bone. Lacerations are classified based on location, length, and depth. Lacerations involving the fingers, toes, and joints must be evaluated for tendon and nerve injury distal to the site and may require subspecialist consultation to evaluate and repair the underlying damage. Lacerations over major blood vessels and arteries should be evaluated for vascular injury, and, if one is found, consultation with the appropriate subspecialist may be necessary. Lacerations can occur over fractures, and fractures can also injure the tissues and protrude through the skin. Lacerations may cause pain and discomfort as well (Figures 9-7 and 9-8).2
Treatment of Lacerations
Treatment of lacerations involves controlling any active bleeding site. When the bleeding is controlled, the wound should be dressed with a dry, sterile dressing. The wound will need to be evaluated for depth, foreign debris, irrigation or wash out, and closure.
Prior to wound closure, the wound should be cleansed with an antimicrobial skin cleanser. Chlorhexidine is a broad-spectrum antimicrobial skin cleanser and antiseptic. It provides long-lasting antimicrobial activity. Then, after cleaning, the affected area can be anesthetized, using a local anesthetic such as Xylocaine (lidocaine), with or without epinephrine. Epinephrine should be avoided in the distal extremities and in any tissue where there is poor vascular supply. Betadine (povidone-iodine), hydrogen peroxide, and alcohol will kill bacteria, but they can also cause irritation to healthy tissue and the wound bed; thus, these agents should be avoided in open wounds.
There are several methods of closing a wound. Location, depth, risk of underlying injury, and infection are all of concern and may contribute to how the wound is closed. Any wound in which there is debris must be copiously irrigated and washed out prior to closure. All lacerations should be closed within 8 hours of injury, as the further treatment is delayed, the more opportunity infection has to occur. However, this needs to be evaluated on a case-by-case basis, depending on the mechanism of injury, site of injury, and degree of tissue damage. Delayed closure is an option; however, it should be reserved for the wounds that are most likely to become infected.
Closure options include dermal adhesives, Steri-Strip (Nexcare) wound closures, stitches, and staples. Dermal adhesives are an excellent choice for a clean, nonbleeding, superficial, small wound. Steri-Strip closures are an alternative to dermal adhesives, but are not a substitute for stitches and staples, which should be used for deeper and longer wounds, or wounds where there is a greater chance of dehiscence or injury. Deep wounds may require multiple-layer closure, in which the deep sutures should be absorbable. Nonabsorbable sutures and staples will need to be removed after a period of time, depending on the location and degree of injury.
For cosmetic purposes, stitches will offer the best wound-edge approximation, closure, and minimized scarring. Staples are an excellent choice for scalp wounds and some post-surgical wounds, as they are made of titanium or stainless steel, which lessens the reaction with the immune system. All wounds, regardless of the method of closure, will heal with a scar. Scars can be revised should they not be to the patient’s liking or form a keloid, which is an overgrowth of scar tissue.
When a wound is closed, it should be washed with soap and water at least once daily, and then either an antibiotic ointment or non-petroleum based, non-scented, non-alcohol–containing moisturizing cream should be applied. The wound should be inspected daily for signs of infection, including redness, purulence, swelling, and pain. If the wound is over a joint, it may require short-term immobilization to prevent damage to the wound bed while it heals. Splinting should be used with caution to prevent joint stiffening, muscle atrophy, and loss of function. If underlying tendon, ligament, or muscle is involved, the patient should be splinted in a position of function, with appropriate referral to a specialist for definitive care. If there is an obvious fracture exposed through a wound, a dry dressing and splint should be applied, and the patient should be transported to a facility capable of handling open fractures.
Penetrating trauma can occur as a result of any object puncturing the skin and entering a body, creating an open wound. The most common penetrating injuries are lacerations; others include stab wounds, gunshot wounds, and impalements. Any penetrating injury needs to be assessed based on location, mechanism of injury, and the potential vascular structures and organs underlying the site of injury. If the penetrating object is impaled in the patient, it should not be removed until potential underlying injury has been ruled out. The only caveat would be in a patient who could not be moved or transported safety due to the object. If the trauma is a stab wound or gunshot, focus should be aimed at hemorrhage control and getting the patient to definitive care.3,4
All patients, regardless of the site of injury or mechanism of injury, should initially be evaluated using the ABCDE method: Airway, Breathing, Circulation, Disability, and Exposure.
- Airway: Does the patient have an airway? If not, and there is no suspected cervical spine injury, open the airway using a head tilt, chin lift. If there is suspected cervical spine injury, a jaw thrust or tongue jaw lift should be used.
- Breathing: Is the patient breathing? If the patient is breathing, is the breathing effective and adequate? If the breathing is inadequate, the patient may require supplemental oxygen, rescue breathing, or ventilation with a bag-valve mask.
- Circulation: Does the patient have a pulse? If not, cardiopulmonary resuscitation should be initiated. If the patient has a pulse, assess whether it is strong or weak and regular or irregular. A weak, fast pulse can be an ominous sign of shock, whereas a strong pulse can indicate adequate blood pressure and tissue perfusion.
- Disability: When vital function has been assessed, locate the site or sites of disability or injury.
- Exposure: Expose the site of disability or injury. This will allow you to adequately assess the site and institute the appropriate care.
For penetrating injuries to the head, neck, chest, abdomen, and pelvis in which there is internal bleeding, this cannot be controlled outside the hospital. The emergency management services system should be activated, and the patient should be transported to the closest appropriate facility. Care must also be taken when evaluating the neck and chest for penetrating trauma.
The head contains the brain, eyes, upper airways, and facial structures. Blunt or penetrating injury can be life-threatening, especially in the case of intracranial bleeding. Any patient with a blunt or penetrating head injury—with or without mental status change, site threatening injury, or airway compromise—should be promptly transported to the closest appropriate facility.
The neck contains the external and internal jugular veins as well as external and internal carotid arteries. Direct pressure is best to control bleeding from these vessels; however, an exsanguinating hemorrhage can occur quickly if not identified and treated promptly. The trachea, if lacerated, can cause respiratory distress, failure, and subcutaneous emphysema. This represents an airway and surgical emergency (Figure 9-9).
The chest contains the heart, aorta, vena cava, lungs, trachea, esophagus, and other great vessels. If not identified and treated quickly, internal injury to any of these organs and vessels can be significant. Any injury to the heart, aorta, other great vessels, or vena cava can lead to exsanguination in the chest cavity. Penetrating or blunt injury to the chest can cause a pneumothorax, hemothorax, or hemopneumothorax.
Pneumothorax (Figure 9-10) is when air leaks into the pleural cavity and causes the lung to collapse. Tension pneumothorax is when the trachea deviates to the side opposite the pneumothorax. A hemothorax is when blood is in the pleural cavity. A hemopneumothorax is when air and blood are in the pleural space. A patient who has a suspected pneumothorax or tension pneumothorax should have a trained provider perform a needle decompression at either the second intercostal space at the mid-clavicular line or fourth intercostal space mid-axillary line. Definitive care includes a thoracostomy tube to allow for lung reexpansion and/or drainage of the hemothorax. If the hemothorax is significant or the bleeding persists, the patient may require an operative intervention to control the hemorrhage and repair any underlying damaged vessels and/or organs.