Rosen & Barkin's 5-Minute Emergency Medicine Consult (414 page)

• Symptoms concerning for an acute stroke or central etiology of vertigo
  
• Intractable nausea and vomiting
  
• Severe dehydration
  
• Unsteady gait
  

• Tolerate oral fluids
  
• Steady gait
  
• Normal neurologic exam
  
• Avoid driving, heights, and operating dangerous equipment
  
• Fall precautions
  
• Arrange neurology or otolaryngology follow-up
  

• Recurrent symptoms
  
• Concern for cholesteatoma
  
• Possible severe underlying conditions such as vertebrobasilar ischemia or brainstem tumor will need consultation from neurologist or neurosurgeon
  

• Vestibular rehabilitation for patients with persistent vestibular symptoms and chronic vertigo due to peripheral vestibular etiology
  
• Auditory brainstem response test is indicated in younger children.
  
• Surgical therapy in the form of labyrinthectomy/posterior canal occlusion/vestibular nerve section, etc., can be considered in cases of refractory vertigo and unsuccessful canalith repositioning procedure.
  

• Counsel patients regarding occupation, fall risk, and driving
  
• Failure to diagnose life-threatening conditions like meningitis, cerebrovascular ischemia, or brain tumors
  
• Take caution while performing physical maneuvers for BPPV, as violent hyperextension at cervical spine can cause vertebral artery dissection
  

• Boston ME. Labyrinthitis.
  Emedicine
  . Updated Feb 22, 2012. Available at:
  http://emedicine.medscape.com/article/856215-overview
  .
  
• Charles J, Fahridin S, Britt H. Vertiginous syndrome.
  Aust Fam Physician.
  2008;37:299.
  
• Kerber KA. Vertigo and dizziness in the emergency department.
  Emerg Med Clin North Am
  . 2009;27:39–50, viii.
  
• Korres SG, Balatsouras DG. Diagnostic, pathophysiologic, and therapeutic aspects of benign paroxysmal positional vertigo.
  Otolaryngol Head Neck Surg
  . 2004;131:438–444.
  
• Kulstad C, Hannafin B. Dizzy and confused: A step-by-step evaluation of the clinician’s favorite chief complaint.
  Emerg Med Clin North Am
  . 2010;28:453–469.
  
• Newman-Toker DE, Camargo CA Jr, Hsieh YH, et al. Disconnect between charted vestibular diagnoses and emergency department management decisions: A cross-sectional analysis from a nationally representative sample.
  Acad Emerg Med
  . 2009;16:970–977.
  
• Schneider JI, Olshaker JS. Vertigo, vertebrobasilar disease, and posterior circulation ischemic stroke.
  Emerg Med Clin North Am
  . 2012;30:681–693.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Dizziness
  
• Vertigo
  
• Ménière Disease
  
• Otitis Media
  
• Mastoiditis
  

CODES

• 386.30 Labyrinthitis, unspecified
  
• 386.31 Serous labyrinthitis
  
• 386.35 Viral labyrinthitis
  

BASICS

• A laceration is a disruption in skin integrity most often resulting from trauma.
  
• May be single or multiple layered
  

Multiple causes

DIAGNOSIS

Lacerations may be accompanied by:

• Bleeding
  
• Tissue foreign bodies
  
• Hematoma
  
• Pain or numbness
  
• Loss of motor function
  
• Diminished pulses, delayed capillary refill
  

• Mechanism and circumstances of injury
  
• Time of injury
  
• History of foreign body (glass, splinter, teeth)
  
• Tetanus immunization
  
• Comorbid condition or medications that may impede wound healing
  

• Evaluate nerve and motor function.
  
• Document associated neurovascular injury.
  
• Assess presence of devitalized tissue, debris from foreign materials, bone or joint violation, tendon injury:
  
  • Avoid digital exploration if the object is believed to be sharp.
    

• Consider repair in OR if unable to be performed safely within the ED, especially for children requiring deep sedation.
  
• Consider surgical consultation for complex lacerations, especially involving eyes and face.
  

Assess for possible nonaccidental trauma.

• Evaluation for possible foreign bodies
  
• Plain radiography:
  
  • Soft-tissue views may aid in visualization.
    
  • Objects with the same density as soft tissue may not be seen (wood, plants).
    
• US
  
• CT scan
  
• MRI with metal precautions
  

• Skin avulsion
  
• Contusion
  
• Abrasion
  

TREATMENT

• Obtain hemostasis, or control of bleeding with direct pressure.
  
• Straighten any flaps of skin whose blood supply may be strangulated.
  
• Apply splint if needed.
  
• Universal precautions
  

• Airway, breathing, and circulation management (ABCs)
  
• Control hemostasis.
  
• Remove rings or jewelry if needed. Swollen fingers with rings can become ischemic.
  

• Time of onset:
  
  • Lacerations may be closed primarily ≤8 hr old in areas of poorer circulation.
    
  • Lacerations may be closed ≤12 hr old in areas of normal circulation.
    
  • On face, lacerations may be closed ≤24 hr if clean and well irrigated.
    
  • If not closed, wound may heal by secondary intention or by delayed primary closure (DPC) in 3–5 days.
    
• Analgesia and conscious sedation:
  
  • Adequate analgesia is crucial for good wound management.
    
  • Conscious sedation may be required (see “Conscious Sedation”).
    
• Local anesthetics:
  
  • Topical:
    
    • TAC (tetracaine, adrenaline, cocaine)
      
    • EMLA (eutectic mixture, lidocaine, prilocaine)
      
    • LET (lidocaine, epinephrine, tetracaine)
      
  • Local/regional:
    
    • Lidocaine, bupivacaine
      
    • Epinephrine will cause vasoconstriction and improve duration of action of anesthetic.
      
    • Avoid epinephrine in the penis, digits, toes, ears, eyelids, tip of nose, skin flaps (necrosis), and severely contaminated wounds (impairs defense).
      
    • For patient comfort, inject slowly with small-gauge needle; buffer every 9 mL of 1% lidocaine with 1 mL 8.4% sodium bicarbonate.
      
    • Consider a 1% diphenhydramine solution in the lidocaine-allergic patient.
      
• Exploration and removal of foreign body:
  
  • Indications for removal of a foreign body include:
    
    • Potential or actual injury to tendons, nerves, vasculature
      
    • Toxic substance or reactive agent
      
    • Continued pain
      
• Irrigation and debridement:
  
  • Surrounding intact skin may be cleaned with an antiseptic solution (povidone-iodine, chlorhexidine):
    
    • Do not use antiseptic solution within the wound itself because it may impair healing.
      
  • Scrub with a fine-pore sponge only if significant contamination or particulate matter.
    
  • Irrigation with ≥200 mL of normal saline (NS):
    
    • Optimal pressure (5–8 psi) generated with 30-mL syringe through 18–20G needle
      
  • Try to avoid shaving hair. Clip if necessary:
    
    • Increased skin infection rate after shaving
      
    • Never shave or clip eyebrow as it may not grow back with a normal appearance
      
  • Debride devitalized and contaminated tissue.
    
• Wound repair:
  
  • Universal precautions
    
  • Wounds that cannot be cleaned adequately should heal by secondary intention or DPC.
    
  • Reapproximate all anatomic borders carefully (e.g., skin–vermilion border of lip).
    
  • Consider tissue adhesive for wounds with clean borders, low tension.
    
• Single-layered closure:
  
  • Simple interrupted sutures:
    
    • Avoid in lacerations under tension.
      
  • Horizontal mattress sutures (running or interrupted):
    
    • Edematous finger and hand wounds
      
    • Ideal in skin flaps where edges at risk for necrosis
      
  • Vertical mattress:
    
    • For wounds under greater tension
      
    • 1 stitch that provides both deep and skin closure
      
  • Half-buried horizontal mattress sutures:
    
    • Ideal for closing the vertex of a v- or y-shaped laceration where ischemia is a concern
      
• Multiple-layered closure:
  
  • Closes deep tissue dead space
    
  • Lessens tension at the epidermal level, improves cosmetic result
    
  • Buried interrupted absorbable suture, simple or running nonabsorbable sutures for epidermis
    
• Dressing:
  
  • Dress wound with antibiotic ointment and nonadherent semiporous dressing.
    
  • Inform patient about scarring and risk for infection, use of sunscreen.
    
  • Apply splint if needed.
    
• Antimicrobial agents:
  
  • Uncomplicated lacerations do not need prophylactic antibiotics.
    
  • If antibiotics are used, initiate before wound manipulation or as early as possible.
    
  • Lacerations with high likelihood of infection:
    
    • Animal, human bites, especially to hand (see “Hand Infection”)
      
    • Contaminated with dirt, bodily fluids, feces
      
  • Tetanus immunization