Wounds and Lacerations: Emergency Care and Closure 3rd Edition
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The goal of managing an auricular laceration is to cover exposed cartilage and limit hematoma formation. If the wound is through-and-through: approximate the posterior surface with non-absorbable sutures, then repair the anterior aspect of the wound with or non-absorbable sutures. Contaminated Wounds Cover cartilage by loose skin approximation and prescribe oral antibiotics.
The contours of the anti-helix are packed with xeroform and sutures are placed through-and-through to hold the packing in place. The area behind the ear is then supported with gauze and the head wrapped with an ace bandage for compression. Auricular Hematomas Auricular hematomas may occur as a result of blunt trauma to the external ear, or as a complication of an auricular laceration repair. Both drainage procedures require compressive auricular dressings so as to avoid hematoma re-accumulation and again the cauliflower deformity.
Similar to auricular laceration repairs, topical or regional anesthesia should be utilized. Disposition Experts recommend that anti- Staphylococcal antibiotics be given, and that patients with auricular hematomas be re-evaluated in 24 hours to search for blood re-accumulation. By contrast, children are likely to shove anything from cheese to rocks in their ears without telling an adult.
Patients with an auricular FB may present with symptoms of ear pain and fullness to tinnitus and vertigo suggesting associated TM rupture. In evaluating an auricular FB, visual inspection of the ear is the most important aspect of the patient encounter.
The following require ENT consultation:. In the majority of cases, young children may require procedural sedation for the removal of auricular FBs.
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Irrigation: Ideal for small objects adjacent to the TM. A G flexible IV catheter can be attached to a 10 cc syringe or a inch section of butterfly needle tubing from which the needle has been removed.
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While these are commercially available in a number of sizes, mm Hg of negative pressure must be generated for the catheter to adequately be used as an extraction tool. Manual Instrumentation: Should be used only when the patient is cooperative, and the object is directly visualized.
Wounds and lacerations : emergency care and closure / Alexander T. Trott - Details - Trove
Instruments range from alligator forceps to cerumen curettes. Superglue: Most effective for smooth, round objects that are difficult to remove with manual instrumentation. If the tip dries against the canal wall, iatrogenic trauma may occur. Fogarty catheters were designed for biliary No.
Both devices function similarly: the catheter is advanced beyond the FB, the balloon gradually inflated with a 3cc syringe, and the FB pulled from the nose, advanced by the inflated balloon. Katz Extractor and Fogarty Catheter Bug Extraction Insects are often removed by manual extraction. If the insect is still alive, mineral oil or viscous lidocaine may be placed into the EAC prior to removal kills the bug, effectively eliminating the difficulty of a moving target, and reducing pain associated with insect movement. In the patient with a FB, do not forget to examine other orifices for a second FB.
This is especially true in children. It is important to note that failure to ensure appropriate patient follow-up has resulted in documented cases of mastoiditis and meningitis. Management is facilitated by local anesthesia and incision for removal. Exploration of any eye injury should include an assessment of EOMs, visual fields, visual acuity, and globe integrity.
Laceration Repair: A Practical Approach
IOP should be assessed if concern for orbital compartment syndrome arises contraindicated in the setting of globe rupture. In addressing eyelid lacerations, it is important to recognize what is and is not appropriate for ED repair. The following lacerations should be referred to a specialist:. Superficial lacerations to the eyelid may be repaired with or non-absorbable nylon or polypropylene simple interrupted sutures. All patients with should be referred to a specialist for aftercare.
Trauma-induced hemorrhage is the most common precipitating factor for orbital compartment syndrome in patients presenting to the ED, 24 however, several conditions may lead to the development of orbital compartment syndrome.
Iserson, et al. In the setting of orbital compartment syndrome, the optic nerve and central retinal artery are compressed, resulting in ischemia and vision loss.
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As the authors note, many practitioners will elect to perform a re-assessment of IOP after release of the inferior crus. If vision returns and the IOP is within normal limits, release of the superior crus is not required. Note: Physical assessment of proptosis and EOMs are much less reliable post-cantholysis, and do not indicated the resolution of the compartment syndrome. Complications Instruments should be directed toward the orbital rim, tangential to the surface of the globe, to avoid iatrogenic EOM or globe injury. Disposition All patients require emergent consultation with a specialist.
The majority of fractures are not reduced until patient follow-up days after initial injury to allow for swelling improvement. If the patient has a simple nasal bridge fracture unilateral fracture of the nasal pyramid , and has no concern about cosmetic outcome, despite discussion regarding poor outcome for impacted or greenstick fractures:. Steps are depicted in the figure below.
Is there a relationship between wound infections and laceration closure times?
An exterior splint should be applied to maintain the reduction. Complications include failed reduction, and nasal trauma secondary to the scalpel handle. All patients require follow-up for splint removal in days. Antibiotics are not indicated. Nasal septal hematomas occur due to trauma to the anterior portion of the nasal septum , and may be seen in the setting of nasal bridge fracture. Missed septal hematomas may result in infection as above , septal perforation, or cartilage destruction resulting in a saddle-nose deformity.
The affected nares should remain packed for 24 hours post hemostasis to ensure perichondrium attachment to the septal cartilage. Approximately 0. Xrays or CT of the sinuses may be obtained in the evaluation of a chronically retained nasal FB. Posterior FBs often require positive pressure for removal. As with auricular FBs, sedation may be required to obtain patient cooperation. Oxymetazoline and topical lidocaine may also aid in FB removal — providing reduction of nasal turbinate edema and pain control.
Similar to auricular FBs, trauma to the nares and nasal mucosa may occur secondary to extraction attempts. Batteries require special attention; as previously mentioned, they quickly cause tissue damage. If unable to expediently remove a disc battery, ENT should be consulted immediately. Magnetic Nose Rings — be on the lookout for patients wearing bilateral magnetic nose rings. Magnets may become displaced with their polarization directed through the nasal septum, subsequently causing pressure necrosis of the nasal mucosa.
Patients may present with nasal pain and purulent drainage which is mistaken for a simple sinusitis. Magnetic Nasal Ring Peritonsillar abscesses PTAs are the most common deep space infections of the head and neck, and frequently occur in the second and third decades of life as sequelae of recurrent tonsillitis or inadequately treated tonsillitis. Peritonsillar cellulitis is often times difficult to differentiate from a PTA, however, intraoral sonography improves diagnostic accuracy. If the superior pole of the tonsil is aspirated initially without pus obtained, the middle and inferior poles should be sequentially aspirated for pus return.
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The carotid artery lies 2 cm posterolateral to the tonsillar pillar and is at risk for injury if the procedure is performed inappropriately. All patients requires hour follow-up to ensure adequate drainage. Incision and Drainage of a PTA Roberts J, and Hedges J. Clinical Procedures in Emergency Medicine 5th ed. Philadelphia, PA: W. Great review. I have had great success with masseter massage. Well tolerated, no sedation needed, patients in and out of the ED in minutes. Your email address will not be published. Save my name, email, and website in this browser for the next time I comment.
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