December 2000 • Volume 7 Number 12
Wound care 101: Take pains with your patients
FP James Tiemann, M.D., of Lee's Summit, Mo., one of 391 attendees at AAFP's first course on emergency and urgent care, examines Erma Fauerbach of Lee's Summit in the emergency department at Lee's Summit Hospital. Tiemann works full time in the hospital's ED, where Fauerbach was brought Nov. 3 with lower-extremity edema and shortness of breath. Sure, you've patched up your share of bumps, scrapes, cuts and other assorted "boo-boos." You've been confronted with Screaming Child, Hysterical Mom and Stoic Dad. (Or maybe it's Stoic Mom and Hysterical Dad -- take your pick; Screaming Child is the constant here.)
What may not be a constant is your approach to wound care. Indeed, different wounds in different patients require different strategies. But there are some general recommendations that can lessen patients' pain and trepidation, said Robert Dachs, M.D., during AAFP's new Emergency and Urgent Care course, held here Oct. 29 Nov. 1.
Dachs, chair of the emergency medicine department at Westerly Hospital in Westerly, R.I., presented a literature-based review of wound care dos and don'ts. Topping the list were tips on injecting local anesthetics.
Buffer it. That looming needle is bad enough, said Dachs. Take some of the sting out by buffering that lidocaine with sodium bicarbonate. A 9:1 ratio works well, he said.
Warm it. An ice cube down the back is rather jarring, don't you think? Same principle applies here. Assuming that neonatal warmer sitting in the corner is unoccupied, consider using it or another method to warm the solution before injection.
Use a small-gauge needle. Choose a 27- or 30-gauge needle, and you're already halfway to the next item ...
Emergency physician Robert Dachs, M.D., demonstrates hair tying as an alternative to scalp suturing. The technique is especially useful in young patients, Dachs said at AAFP's recent emergency care course in Scottsdale, Ariz. Inject slowly. "You just can't push as much through a 30-gauge needle," said Dachs.
Inject inside the wound. It's already open. You don't need to poke through the skin.
With intact skin (e.g., biopsy), pinch it. Using your thumb and forefinger, pinch repeatedly just behind the injection area.
Augmenting the anesthetic with epinephrine extends the numbing effect, said Dachs. Caution is justified with extensive injection of this combination into a digit when circulation may be compromised. However, he said, anecdotal reports of ischemic necrosis resulting from injection of combined solution into digit stems have created unnecessary concern.
"With a young, healthy person, if you happen to pull out the lidocaine with epi, don't worry about it," Dachs said. "You don't have to call up your malpractice attorney and say, 'Oh god, I just lopped somebody's fingers off!'"
Alternatives to lidocaine for infiltration anesthesia are plentiful. Some, such as bupivacaine, offer a longer duration of action with no loss in rapidity of effect onset.
Topical anesthetics may be just the thing for some of your youngest patients. A solution of lidocaine-epinephrine-tetracaine, or LET (also called lidocaine-adrenaline-tetracaine, or LAT), and eutetic mixture of local anesthetics cream, or EMLA, are viable options for certain uncomplicated wounds.
When it comes to closing wounds, suturing's not the only game in town. Dachs described three other options.
Hair tying. This technique works particularly well in youngsters with scalp wounds that aren't under a lot of tension, said Dachs. The benefits of using the child's own hair in place of suture materials include less pain and lower costs, and there's no need for a return visit.
Staples. "I just love doing this," said Dachs. "I think it's the neatest thing since sliced bread." He described a case where the patient had "basically scalped himself" running under a trailer. "If I'd been using sutures on this patient, it would've taken all day to stitch him up," he said.
Tissue adhesives. Basically Super Glue® for the skin, it's quick, easy and does a great job, Dachs said.
There's only one caveat, he added: "Get your fingers out of the way!"
FP Report is published by the AAFP News Department.
Copyright © 2001 by American Academy of Family Physicians.
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