Rosen & Barkin's 5-Minute Emergency Medicine Consult (260 page)

• Edema, erythema, and significant ear tenderness
  
• Toxic patient with fever and chills
  
• Immunocompromised patient
  

Stable patient without systemic signs with close ear, nose, and throat (ENT) follow-up

ENT consult:

• For chondritis, abscess, and necrosis of the involved cartilage
  
• Early surgical drainage for chondritis and abscess
  

Aggressive early management may prevent gross ear deformity:

• Antibiotic regimen should cover for Pseudomonas.
  

• Fisher CG, Kacica MA, Bennett NM. Risk factors for cartilage infections of the ear.
  Am J Prev Med
  . 2005;29(3):204–209.
  
• Guss J, Ruckenstein MJ. Infections of the external ear. In: Cummings CW, Flint PW, Haughey BH, et al., eds.
  Otolaryngology: Head & Neck Surgery
  . 5th ed. Philadelphia, PA: Mosby Elsevier; 2010: chapter 137.
  
• Rowshan HH, Keith K, Baur D, et al. Pseudomonas aeruginosa infection of the auricular cartilage caused by “high ear piercing”: A case report and review of the literature.
  J Oral Maxillofac Surg
  . 2008;66(3):543–546.
  
• Van Wijk MP, Kummer JA, Kon M. Ear piercing techniques and their effect on cartilage, a histologic study.
  J Plast Reconstr Aesthet Surg.
  2008;61(suppl 1):S104–S109.
  

CODES

• 380.03 Chondritis of pinna
  
• 380.10 Infective otitis externa, unspecified
  

BASICS

Penetrating injury to extremity

• Stab or puncture
  
• Gunshot
  
• Laceration
  
• Bite
  
• High-pressure injection injury
  

DIAGNOSIS

• Entry and exit wound (if present), lacerations
  
• High-muzzle–velocity gunshot wounds:
  
  • Produce shock wave that results in significant tissue injury
    
  • Often exit wound demonstrates more tissue damage than entrance wound.
    
• Vascular injury:
  
  • Arterial injury:
    
    • Decreased or absent distal pulse
      
    • Distal ischemic changes
      
    • Expanding hematoma
      
    • Bruit or thrill over injury
      
  • Presence of distal pulse does not exclude proximal vascular injury.
    
• Neurologic injury:
  
  • Paresthesias
    
  • Decreased or absent motor function
    
  • Diminished sensation distal to injury
    
• Musculoskeletal injury:
  
  • Visible deformity
    
  • Ligamentous laxity in joints adjacent to injury suggests tendon injury.
    
  • Effusion in adjacent joint indicates fracture or ligamentous injury.
    
• Compartment syndrome:
  
  • Suggested by severe and constant pain over involved compartment
    
  • Pain on active and passive extension or flexion of distal extremity
    
  • Weakness, pain on palpation of compartment
    
  • Hypesthesia of nerves in compartment
    
  • Pulselessness and pallor are late findings.
    

• Mechanism of injury
  
• Age of wound
  
• Circumstances of wounding:
  
  • Assault
    
  • Self-inflicted wound
    
  • Domestic violence
    
• Comorbid conditions:
  
  • Immunosuppression or diabetes
    
  • Valvular heart disease
    
  • Asplenia
    
  • Peripheral vascular disease
    

• Note location, length, depth, and shape of primary wound and exit wound, if present.
  
• Vascular injury:
  
  • Compare distal pulses by palpation and with Doppler study.
    
  • Assess capillary refill:
    
    • Abnormal if >2 sec
      
  • Ankle–brachial index (ABI):
    
    • Take BP in calf and arm (involved extremity).
      
    • Systolic pressure difference of >10 mm Hg suggests vascular injury.
      
  • Expanding hematoma, bruit, or thrill over injury also indicates vascular injury.
    
• Neurologic injury:
  
  • Assess distal motor function and sensory function:
    
    • 2-point discrimination
      
    • Light touch
      
    • Proprioception
      
• Musculoskeletal injury:
  
  • Note associated crush, tendon, or ligamentous injury and bony deformity.
    
  • Examine adjacent joints for range of motion.
    
  • Assess for compartment syndrome.
    
• Explore wound for foreign body (FB).
  

• Physical exam
  
• Imaging if findings suggestive of bony injury or possible FB
  

• Culture of acute wounds is not indicated.
  
• Wounds with signs of infection may be cultured to guide antibiotic choice.
  

• Radiograph to evaluate for radiopaque FB or underlying fracture:
  
  • Min. AP and lateral views
    
• Radiolucent FBs may be located by US, fluoroscopy, or CT.
  

Arteriogram is indicated when vascular injury is suspected and immediate vascular surgery not required.

Any medical condition that presents with findings consistent with extremity trauma or a wound

TREATMENT

Cautions:

• Control hemorrhage with direct pressure over site.
  
• Elevate extremity.
  
• Evaluate neurovascular status.
  
• Leave impaled objects in place and stabilize in current position.
  
• Pain control
  

• Manage airway and resuscitate as indicated.
  
• Expose wound completely and remove constricting clothing or jewelry.
  
• Control hemorrhage with direct pressure.
  
• Blind clamping within wound and prolonged tourniquet use are not recommended.
  

• Pain control
  
• Complete neurologic assessment before local anesthesia
  
• Prolonged soaking of wounds, particularly with cytotoxic agents, is
  not
  recommended.
  
• Remove any visible debris and débride devitalized tissue.
  
• Most important is copious high-pressure irrigation with saline.
  
• Tetanus prophylaxis
  
• Stab wounds and gunshot wounds should receive single dose of cefazolin in ED.
  
• Immobilize extremity if there is suspicion of significant vascular injury, tendon injury, fracture, or joint violation.
  
• Loss of pulse or distal ischemia requires emergent surgery:
  
  • Do not delay surgical management for arteriogram.
    
• Lacerations may be closed if they have been adequately cleaned, have minimal tissue loss, and are seen within 6–8 hr of injury:
  
  • Delayed primary closure is an alternative for older or contaminated wounds.
    
• Puncture or gunshot wounds should
  not
  be closed primarily.
  
• Special considerations:
  
  • Plantar puncture wounds:
    
    • Examine wound carefully under bright light.
      
    • Remove any foreign material.
      
    • Clean wound carefully.
      
  • Coring wound is controversial and should be reserved for removal of devitalized tissue or imbedded debris:
    
    • Probing or high-pressure irrigation of puncture wound will only force particulate matter further into wound.
      
    • Prophylactic antibiotics are not recommended (unless patient is diabetic or immunocompromised or if the wound is highly contaminated or delayed in presentation).
      
  • If not treated with aggressive debridement, can lead to osteomyelitis
    
  • High-pressure injuries of hand:
    
    • Orthopedic evaluation in ED is essential because wounds that appear trivial on surface may have product track up tendon sheaths into more proximal aspects of hand.
      
    • Some paints and other products are radiopaque, and plain radiographs may demonstrate extent of spread.
      
  • Soft tissue FBs:
    
    • Small inert FB in wound, including bullets, not easily retrievable and not in close proximity to joint, tendon, vessel, or nerve can be left in place with close follow-up.
      
    • FB in hands and feet should be referred to specialist as they often migrate and become or remain symptomatic.
      
    • Organic materials (thorns, wood, spines, clothing) should be removed as they are very reactive.