tern, altered mental status is not uncommon. Jugular

venous distention, cardiac murmurs, and pulmonary rales

often accompany cardiogenic shock. A careful skin examination can be invaluable, as patients in distributive shock

frequently exhibit warm hyperemic extremities, whereas

those in cardiogenic, hypovolemic, and obstructive shock

will present with cool mottled extremities secondary to

profound systemic vasoconstriction. Furthermore, abnormal findings such as diffuse urticaria, pronounced erythema, or widespread purpura may help identify the t ype

and source of shock. The abdominal exam should focus on

careful palpation and looking for signs of peritonitis or a

pulsatile mass. Measure urine output, as low volumes indicate an absolute or relative volume deficiency and may help

guide resuscitation.

DIAGNOSTIC STUDIES

� Laboratory

No single laboratory test is diagnostic of shock. Complete

blood count testing may reveal an elevated, normal, or

low white blood cell (WBC) count. No matter the absolute WBC count, a bandernia >10% suggests an ongoing

infectious process. Comprehensive metabolic panel analysis will assess both kidney and liver function and acidbase status. An elevated anion gap may indicate underlying

lactic acidosis, uremia, or toxic ingestion. Blood gas

analysis is useful to determine the serum pH, lactate

level, and base deficit. Serum lactate is a highly sensitive

marker for tissue hypoperfusion and predictive of overall

SHOCK

mortality in septic shock. Lactate levels >4 rnmol!L are

significant and indicate ongoing cellular hypoxia. Other

tests useful in the appropriate clinical scenario include

cardiac markers, urinalyses, coagulation profiles, toxicologic screens, and pregnancy testing. Obtain blood and

urine cultures (and possibly cerebrospinal fluid) if sepsis

is a concern.

� Imaging

No single radiologic test is diagnostic of shock. Chest

x-ray may reveal evidence of an infiltrate (sepsis),

enlarged cardiac silhouette (cardiac tamponade), subdiaphragmatic free air (sepsis), pulmonary edema (cardiagenic shock) or pneumothorax. Bedside ultrasound can

guide the work-up, treatment, and disposition of patients

in shock in multiple clinical situations including sepsis,

blunt abdominal trauma, pregnancy, abdominal aortic

aneurysm, and pericardia! tamponade. Furthermore,

ultrasonographic inferior vena cava measurement can

help guide appropriate fluid resuscitation. Computed

tomography imaging has become the modality of choice

for diagnosing PE, aortic dissection, and intra-abdominal

pathology.

PROCEDURES

Endotracheal intubation may be required in patients with

profound shock to reduce the work of breathing and systemic metabolic demands. Central venous line placement

can expedite fluid or blood product infusion, vasopressor administration, and central venous pressure (CVP)

analysis.

 

et al. Part 1: Executive Summary: 2010 American Heart

Association Guidelines for Cardiopulmonary Resuscitation

and Emergency Cardiovascular Care. Circulation. 20 1 0; 122:

S640-S656.

Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, et al .

Part 8: Adult Advanced Cardiovascular Life Support: 2010

American Heart Association Guidelines for Cardiopulmonary

Resuscitation and Emergency Cardiovascular Care.

Circulation. 2010;1 22:S729-S767.

Omato, JP. Sudden cardiac death. In: Tiutinalli JE, Stapczynski

JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD. Tintinalli's

Emergency Medicine: A Comprehensive Study Guide. 7th ed.

New York, NY: McGraw-Hill, 201 1, pp. 63--67.

Airway Management

Theresa M. Schwab, MD

Key Points

• Rapid-sequence intubation (RSI) is the preferred method

for endotracheal tube placement in the emergency

department.

• The decision to intubate should always be made on

clinical grounds. Time permitting, assess for factors

predictive of a difficult airway before RSI.

INTRODUCTION

Successful airway management depends on the prompt

recognition of an inadequate airway, the identification of

risk factors that may impair successful bag-valve-mask

(BVM) ventilation or endotracheal t ube (ETT) placement,

and the use of an appropriate technique to properly secure

the airway. The decision to intubate is a clinical one and

should be based on the presence of any 1 of 3 major conditions: an inability to successfully protect one's airway

against aspiration/occlusion, an inability to successfully

oxygenate the blood (hypoxemia), or an inability to successfully clear the respiratory byproducts of cellular

metabolism (hypercapnia). Additional indications including the desire to decrease the work of breathing (sepsis),

the need for therapeutic hyperventilation (increased intracranial pressure [ICP]), and the need to obtain diagnostic

imaging in noncooperative individuals (altered mental

status) should be taken into account on a patient-bypatient basis.

Techniques for the management of unstable airways

range from basic shifts in patient positioning to invasive

surgical intervention. Standard basic life support recommendations such as the head-tilt chin-lift maneuver may

open a previously occluded airway. Oropharyngeal and

nasal airway adjuncts are both simple to use and highly

37

 

• General criteria for endotracheal intubation include a

failure to protect the airway, a failure to adequately

oxygenate, and a fa ilure to expire accumulating co r

• Pursue alternative techniques (eg, cricothyrotomy) in

patients when the in itial airway intervention has fa iled

and the patient cannot be adequately ventilated.

effective in this setting, but are unfortunately often underutilized. Failure to respond to these measures warrants the

placement of an ETT. Rapid-sequence intubation (RSI)

combines the careful use of pretreatment interventions with

the administration of induction and paralytic agents to create the ideal environment for ETT placement and is the

preferred method in the emergency department (ED).

A patient who cannot be intubated within 3 attempts is

considered a failed airway. This scenario occurs in -3-5%

of all cases. Numerous alternative devices including laryn ­

geal mask airways (LMA), introducer bougies, and fiberoptic instruments have been developed to facilitate airway

management in these situations. That said, these methods

are not failsafe, and roughly 0.6% of patients will require a

surgical airway. Emergent cricothyrotomy is the preferred

surgical technique for most ED patients.

CLINICAL PRESENTATION

.... History

The need for immediate airway intervention in emergency

situations always supersedes the need for a comprehensive

history and physical exam. Time permitting, perform a

rapid airway assessment to identify any risk factors predictive of a difficult airway, inquire about any current

CHAPTER 11

medication use and known drug allergies, and try to ascertain the immediate events leading up to ED presentation.

Risk factors predictive of a difficult airway include

those that impair adequate BVM ventilation and those that

preclude successful placement of an ETT. Examples of the

former include patients with facial trauma and distorted

anatomy, obese patients with excessive cervical soft t issue,

and asthmatic patents with excessively high airway resistances. Examples of the latter include patients with a his ­

tory of degenerative changes of the spine that limit cervical

mobility ( eg, rheumatoid arthritis, ankylosing spondylitis),

patients with underlying head and neck cancers that distort the normal cervical anatomy, and those with excessive

swelling of the airway and surrounding tissues (eg,

angioedema).

..... Physical Examination

Rapidly examine the airways of all critically ill patients.

 

� Imaging

If the patient has a ROSC, obtain a chest x-ray to evaluate

endotracheal tube placement and an electrocardiogram to

evaluate for cardiac ischemia.

PROCEDURES

Pericardiocentesis is indicated if there is a suspicion of

cardiac tamponade in the setting of PEA. Bedside ultra ­

sound can be useful if tamponade is suspected. A long

spinal needle is inserted s ubxiphoid into the pericardia! sac

aimed toward the left shoulder. Pull back on a 60-mL

syringe while advancing the needle until blood is obtained.

A needle thoracostomy is indicated if there is a s uspicion of tension pneumothorax in the setting of PEA. I nsert

an 1 8-gauge needle into the second intercostals space in

the midclavicular line. A needle thoracostomy must always

be followed by a tube thoracostomy in patients with

ROSC.

MEDICAL DECISION MAKING

The differential diagnosis for SCD is broad. Management

of SCD depends on the presenting rhythm; however, every

patient should receive continuous high-quality uninterrupted chest compressions. Defibrillate VF/pulseless VT.

Administer epinephrine for asystole and PEA. Attempt to

correct reversible causes of PEA, the H's, and T's

(Table 10-1). Once ROSC occurs, initiate postresuscitative

care, including therapeutic hypothermia, which improves

neurologic outcome.

Table 1 0-1. The H's and T's of PEA.

Hypoxia

Hypovolemia

Hydrogen ion (acidosis)

Hypo-/hyperkalemia

Hypothermia

Toxins

Tamponade (cardiac)

Tension pneumothorax

Thrombosis (pulmonary, cardiac)

TREATMENT

If there is a clear, written, advanced directive signed by the

patient or medical power of attorney stating that resuscitative efforts should not be instituted, or if the resuscitation

would be futile because of clear signs of irreversible death

(decapitation, rigor mortis), resuscitative efforts should

not be initiated or continued.

The resuscitative team must orchestrate simultaneous

assessment and management of patients in cardiopulmo ­

nary arrest.

1. Defibrillation. Indicated for patients in VF or pulseless

VT. The rate of successful defibrillation when attempted

within 1 minute of VT is >90o/o, but falls lOo/o with each

subsequent minute.

 

Always consider the presence of concurrent cervical spine

injury in victims of trauma and immobilize as appropriate.

Carefully examine the face, noting any signs of significant

facial trauma and the presence of a beard, both of which

frequently impair adequate BVM ventilation. Inspect the

oropharynx, noting the presence of dentures; the size of

the teeth and presence of a significant overbite; visibility of

the soft palate, uvula, and tonsillar pillars (ie, Mallampati

classification); and the presence of significant airway swelling. The pooling of blood or secretions in the oropharynx

indicates an inability to properly protect the airway. A good

adage to remember when assessing the airway is the 3-3-2

rule. The inability to open the mouth 3 finger breaths, a

distance from the tip of the chin to the base of the neck less

than 3 finger breaths, or a distance between the mandibular floor and the prominence of the thyroid cartilage of less

than 2 finger breaths all predict more difficult ETT place ­

ment. Assess the range of motion of the cervical spine,

provided there is no concern for occult injury.

DIAGNOSTIC STUDIES

..... Laboratory

Although abnormalities on either blood gas analysis (hypercapnia) or pulse oximetry (hypoxemia) may be indicative of

an inadequate airway, normal values on either of these studies should not j ustify the delay of definitive intervention in

the appropriate clinical scenario. Progressive abnormalities

on serial testing (increasing PaC02

, decreasing Pa02

) in

patients who are clinically decompensating indicates the

need for airway intervention.

..... Imaging

Imaging studies should not be used to predict the need for

airway intervention. Obtain a chest x-ray (CXR) in all

patients after intubation to confirm proper ETT placement.

The tip of the ETT should be visualized approximately

2 em above the carina. Deeper insertion results in placement into the right mainstem bronchus.

MEDICAL DECISION MAKING

Consider all rapidly reversible causes of airway compromise

(eg, hypoglycemia, opioid overdose) before pursuing endotracheal intubation. Proper intervention may transform a

comatose patient with a rather tenuous airway into an awake

coherent individual with adequate airway protection.

Identify patients who are likely to present a difficult airway

and those who require specialized approaches ( eg, head

trauma precautions, hypotension, cervical spine injury) and

proceed accordingly (Figure 1 1-1).

PROCEDURES

..... Bag-Valve-Mask Ventilation

Proper BVM ventilation requires an open airway and an

airtight seal between the mask and the patient's face. Use

the head-tilt chin-lift technique (jaw-thrust maneuver in

trauma victims) to open the airway and insert oropharyngeal or nasal adjuncts as necessary to maintain patency.

Avoid the use of oral adjuncts in patients with intact gag

reflexes and nasal adjuncts in patients with significant

mid-face trauma. With proper technique and a high-flow

oxygen source, this method can provide an Fi02 of

approximately 90% ( Figure 1 1-2).

..... Rapid-Sequence Intubation

Preoxygenate all patients with a high-flow oxygen source

(eg, nonrebreather [NRB] mask) for several minutes as

time permits before RSI. Avoid positive pressure ventilation

(eg, BVM) to prevent insufflation of the stomach, which

can increase the patient's risk for aspiration. Use this time

to prepare and check your equipment. Ensure adequate N

access and proper function of the suction device. Remove

 

An area is inaccessible to ground traffic.

The use of local ground resources would leave an area temporarily

without adequate resources.

.,..._ Facilities/Critical Care Units

In general, prehospital patients are transported to the closest appropriate medical facility. There are some situations

in which a patient's preference may dictate hospital desti ­

nation. One issue that has emerged as a product of hospital

overcrowding is ambulance diversion, where ambulances

may need to bypass the closest appropriate facility to transport to another center that has capacity. Another factor in

hospital destination is availability of specialty care for

time-critical diagnoses. Examples of field triage and transport for time-critical illnesses include designated "trauma

centers;' facilities with surgical teams and operating rooms

on standby; "stroke centers;' with immediately available

neurology and neurosurgical capabilities; and "cardiac

centers;' with cardiac catheterization laboratories and

therapeutic hypothermia resources readily available for

patients with acute coronary syndromes or cardiac arrest.

Obstetrical, pediatric, and burn centers are recognized in

some regions as specially designated receiving facilities.

.,..._ Public Safety Agencies

Prehospital responses are often coordinated efforts between

police, fire, and EMS personnel. Various paradigms for the

division of labor within a given municipality exist. Some of

the more common EMS structures include fire-based,

third-service, private, and hospital-based. Fire-based

ambulances are staffed and operated by the local fire

department, whereas in third-service systems, EMS are

separate from both police and fire departments. Private

ambulance companies may provide nonurgent transports

CHAPTER 9

or may operate under contract with local governments to

supplement or provide all emergency care for a municipality. Lastly, hospital-based ambulances have crews of

hospital-employed personnel dispatched on ambulances

owned by the hospital.

..... Consumer Participation/Public

Information and Education

An important aspect of most EMS operations is community service, ranging from public relations expositions to

educational initiatives like CPR training. It is also common

for public representatives to participate in the oversight

and decision making that takes place within a public EMS

organization. EMS is often described as existing at the

intersection of public safety and public health; EMS data

and personnel are a critical link in public health infrastructure and preventative interventions.

..... Patient Transfer

One of the primary purposes of EMS is to deliver patients

to the care that they need. In many cases, this involves

transport from the scene of an injury or medical event to a

receiving hospital, but it may also involve the transport of

a patient from one medical facility to another. A key legislative mandate set forth in the Emergency Medical

Treatment and Active Labor Act (EMTALA) is that an

appropriate medical screening exam must be performed to

identify emergent medical conditions that must be stabilized before a patient can be considered for transfer to

another facility. Receiving hospitals must explicitly accept

a transfer before a patient is transported.

..... Coordinated Patient Record Keeping

T�e method of charting varies from one system to another,

W1th many systems now implementing an electronic medical record. A significant barrier to prehospital research is

the tremendous variation that exists in charting methods,

 

data definitions, and reporting requirements. There is also

difficulty linking prehospital data to hospital or outcomes

data.

..... Review and Evaluation

The care rendered by prehospital providers is overseen by a

physician medical director. Day-to-day operations generally

function using either "standing orders" (offline medical

control-protocols developed to guide patient care) or

online medical control (real-time telephone/radio communication with hospital personnel to answer clinical questions

or to receive orders). Protocols undergo periodic review for

updates based on changing system needs and current science. Proactive systems have robust continuous quality

Table 9-3. The "Simple Triage and Rapid Treatment"

(START) system.

Green (minor)

Yellow (delayed)

Red (immediate)

Black (deceased)

Care may be delayed (eg, non-l imbthreatening extremity trauma)

Will require urgent care (eg, hemorrhage

with signs of adequate perfusion)

Requires immediate care for life-threatening

injury (eg, severe hemorrhage or airway

compromise)

Either dead or mortally wounded, such that

dedication of any additional resources is

unl ikely to alter outcome

improvement processes, by which EMS data are used to

identify areas of the system in need of improvement .

..... Disaster Plan/Preparedness

Emergency response plans exist at local, state, and national

levels. Key features include provisions for interagency

communication and agreements regarding the optimal

allocation of limited resources when a system's capacity is

exceeded-a situation referred to as a mass casualty incident. In these situations, the "Simple Triage and Rapid

Treatment" (START) algorithm is a commonly employed

triage protocol used to assess severity of injury and to

assign transport priority. Providers assign 1 of 4 colors to

victims during an initial assessment focused on the ABCs

(Table 9-3).

..... Mutual Aid

Agreements among neighboring municipalities or EMS

services are common to bolster the capacity of a given

agency's emergency response system. Interagency communication and equipment interoperability are potential

challenges that need to be addressed in establishing such

relationships.

SUGGESTED READING

Emergency Medical Services: Clinical Practice and Systems

Overstght. National Association of EMS Physicians. Dubuque,

IA: Kendal/Hunt, 2009.

Mechem CC. Emergency medical services. ln: Tintinalli JE,

 

..... Manpower

The workforce providing prehospital care varies largely

based on population density. Urban areas typically have

paid providers serving through government agencies or as

public safety officers in large public venues (airports,

amusement parks, etc). Volunteers are more commonly

found in suburban, rural, and wilderness areas.

..... Training

The U.S. Department of Transportation (DOT) National

Highway Traffic Safety Administration (NHTSA) National

Standard Curriculum for prehospital care providers historically outlined 4 levels of training: first responder, EMTbasic, EMT-intermediate, and EMT-paramedic. Currently,

• In 201 2, the American Board of Medical Specia lties

approved EMS as a subspecialty.

these levels are being transitioned to 4 nationally standardized levels of certification: emergency medical responder

(EMR), emergency medical technician (EMT), advanced

EMT (AEMT), and paramedic. Each level of training infers

a specific role, skill set, and knowledge base (Table 9- 1).

EMS provider training at all levels emphasizes airway,

breathing, and circulation (ABCs) and provider scene

safety as priorities in patient care. Although significant

efforts have been made to standardize education and certification throughout the United States, variability exists

from state to state in scope of practice and specific medication usage by each level of prehospital provider .

..... Communications/ Access to Care

In the early 1970s, "9-1-1" became the now ubiquitous

common point of access to emergency services. Call cen ­

ters are typically staffed by trained dispatchers who practice priority dispatching. Their job is to gather sufficient

information to triage and allocate the most appropriate

resources for a given response. It is becoming increasingly

common for dispatchers to provide pre-arrival

instructions to the caller, such as how to perform

layperson CPR.

..... Transportation

Transport vehicles vary in equipment based on the

intended response model and provider scope of practice.

30

EMERGENCY MEDICAL SERVICES

Table 9-1 . Prehospital care providers.

Certification Level Description

Emergency medical responder (EMR} The first responders to arrive on scene, they are trained to perform immediate lifesaving care with limited

resources until additional EMS responders arrive. Their skill set includes CPR, spinal immobil ization, oxygen administration, hemorrhage control, and use of an automated external defibrillator (AED}.

Emergency medical technician (EMT) This is the basic level of training necessary for ambulance operations. EMTs' skill set includes that of the

EMR, with the addition of transport operations and the assistance of patients in taking some of their

own prescription medications, such as metered-dose inhalers or nitroglycerine tablets. They may also

provide several medications including oral glucose, aspirin, albuterol, and epinephrine for anaphylaxis.

Advanced emergency medical

technician (AEMT}

Under medical direction, the AEMT may initiate intravenous or intraosseous access, perform manual defibril lation, interpret electrocardiograms, and administer an expanded range of medications.

Paramedic Traditionally the highest prehospital level of training with the broadest scope of practice. Their expanded

skill set includes endotracheal intubation, cricothyrotomy, needle thoracostomy. Drug administration

includes vasoactive agents, benzodiazepines, and opiates for pain control. They are also trained to perform higher level ECG analysis and to provide antiarrhythmic therapy with medications, electrical cardiaversion, manual defibrillation, and transcutaneous pacing.

Critical care paramedic This is a provider level that reflects additional training, knowledge, and scope of practice that is needed

for initiating or maintaining advanced level intervention during transport. Critical care paramedics often

have training in chest tube placement and management, balloon pump management, neonatal care,

central venous catheters, arterial lines, and hemodynamic monitoring. Additional medications including

neuromuscular blockers and sedation agents are commonly used at this level of care .

Basic life support ( BLS) ground units have automated

external defibrillators (AED) and supplies necessary for

basic wound care and airway management, including

oxygen, bag-valve-masks, suction equipment, and oral

and nasal airways. Advanced life support (ALS) units

have equipment necessary for a paramedic's scope of

practice, including equipment for IV access, medications,

and a cardiac monitor/defibrillator for rhythm analysis

and intervention. Some systems have uniquely equipped

critical care transport units that are designed to

accommodate patients with continuous IV infusions,

ventilators, or other specialized medical equipment such

as intra-aortic balloon pumps or neonatal incubators.

Air medical transport comprises both fixed-wing

(airplane) and rotary-wing (helicopter) vehicles. General

indications for air medical transport are outlined in

Table 9-2.

Table 9-2. Relative indications for air medical transport.

Distance by ground to the closest appropriate medical facil ity is too

great for safe and timely transport.

A delay during ground transport would likely worsen the patient's

clinical condition.

Special ized care is not available from local ground response

agencies.

 

Probes send out and receive information via the piezoelectric or the pressure-electricity effect. The probe relies on

a complex, delicate, and expensive arrangement of crystals.

These crystals convert electrical energy to mechanical energy

in the form of sound waves. Returning sound waves are

translated back into electricity by the probe. Probe mainte ­

nance is of utmost importance; a probe must never be used

if cracked or otherwise significantly damaged.

Frequency. The higher the frequency of sound waves

emitted by the probe, the greater the tissue resolution, but

the lower the depth of penetration. Different types of probes

exist for different clinical questions. Low-frequency probes

(2-5 MHz) are used in thoracic and abdominal imaging to

visualize deeper structures. High-frequency probes (8--10 MHz)

are used in procedural applications, such as central line

placement and nerve blocks, to visualize more superficial

structures with more detailed resolution.

Echogenicity. Images are described in terms of echogenicity. Dense bone is highly reflective, appearing bright

or hyperechogenic. Less dense organ parenchyma appears

grainy or echogenic. Fluid-filled structures or acute bleeding do not reflect, appearing black or anechogenic. Air has

an irregular reflective surface and appears as bright scatter

with dirty posterior shadows.

Orientation. A marker on the US probe corresponds to

an indicator on the screen. By accepted standard in emergency medicine and radiology, the indicator is always on the

physician's left side of the screen. In the sagittal (longitudinal) anatomic plane, the probe marker is pointed at the

patient's head, resulting in the head being displayed toward

the left side of the screen and the feet toward the right

(Figure 8- lA). In the coronal (transverse) anatomic plane,

the probe marker is pointed at the patient's right, resulting

in the patient's right side being displayed on the left side of

the screen, similar to viewing a CT scan image (Figure 8-1B).

Modes. The most commonly used mode is the brightness (B) mode on the US machine. Other modes include

the motion (M) mode, often used to measure the fetal

heartbeat, as well as the Doppler and color flow modes to

measure blood flow.

A

8

 

principles of spacing as above.

Tissue adhesive is applied using 4-5 layers on a hemostatic, cleaned, dry wound, which the provider approximates while applying the adhesive. Avoid getting the

adhesive into the wound itself. Wound tape may be applied

to the wound before placing the adhesive to provide

improved approximation.

\

\

\�

.A. Figure 6-4. Horizonta l mattress.

\

\

\

LACERATION REPAIR

Figure 6-5. Deep dermal stitch. On the first pass,

the needle enters at the depth of the wou nd so that

the knot wi ll end up at the bottom of the wound.

..... Wound Aftercare

Topical antibiotic ointments provide a moist environment

that assists epithelization and reduces the rate of infection.

They should not be used after the use of tissue adhesive.

Prophylactic oral antibiotics are r ecommended for heavily

contaminated wounds, significant animal or human bites,

areas prone to infection (mouth, plantar aspect of the

foot), open fractures, tendon or joint involvement, immunocompromised patients, a prosthetic heart valve, or deep

puncture wounds.

In patients with full childhood immunizations, tetanus

toxoid, given with diphtheria toxoid (Td 0.5 mL administered intramuscularly [IM) ), is administered after a minor,

clean wound if the last booster was > 10 years ago. In all

other wounds (contaminated, puncture, crush), tetanus

toxoid is given if the last booster was >5 years ago. Tetanus

immune globulin (TIG) 3,000-5,000U IM and around the

wound is administered to patients with a history of <3

immunizations and a contaminated wound.

Apply a topical ointment ( eg, bacitracin) and then a

sterile dressing. The dressing may be removed in 24 hours

and the wound can be gendy cleansed with soap and water,

using caution to blot the sutures dry.

Suture removal is recommended in 3-5 days for face

and neck; 7-10 days for upper extremity, chest, legs, and

scalp; and 10-14 days for hand, back, buttocks, foot, and

overlying joints.

COMPLICATIONS

Complications may include infection and scarring. Despite

all efforts to reduce the risk of infection, this complication

can still occur. The patient should be instructed to return

at the first signs of infection (ie, fever, purulent drainage,

or erythema). Patients with high-risk wounds should be

asked to return to their physician or the emergency department within 24-48 hours to have the wound reexamined

by a physician. Patients should also be instructed that a

scar will form with healing. Scarring is more significant

after deeper wounds, or those that do not run parallel to

natural skin lines, and when absorbable sutures are used.

There are insufficient data to recommend routine use of

topical healing creams such as vitamin E, aloe vera, or

other commercially available products.

SUGGESTED READING

Desai S, Stone SC, Carter WA. Wound preparation. In:

Tintinalli JE, Stapczynski JS, Ma OJ, Clince DM, Cydulka,

RK, Meckler GD. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, NY: McGraw-Hill, 20 1 1,

pp. 301-306.

Singer AJ, Hollander JE. Methods for wound closure. In:

Tintinalli )E, Stapczynski JS, Ma OJ, Clince DM, Cydulka, RK,

Meckler GD. Tintinalli's Emergency Medicine: A Comprehensive

Study Guide. 7th ed. New York, NY: McGraw-Hill, 20 1 1,

pp. 306-3 15.

Singer AJ, Hollander JE, Quinn JV. Evaluation and management

of traumatic lacerations. N Eng! J Med. 1997;337:1 142-1 148.