Chapter 132: Common skin wounds and foreign bodies

Injuries to the skin, including simple lacerations, abrasions, contusions and foreign bodies, are among the commonest problems encountered in general practice. To manage these cosmetically important injuries well is one of the really basic and enjoyable skills of our profession.

A contusion (bruise or ecchymosis) is the consequence of injury causing bleeding in subcutaneous or deeper tissue while leaving the skin basically intact. It might take weeks to resolve, especially if extensive.

A haematoma is a large collection of extravasated blood that produces an obvious and tender swelling or deformity. The blood usually clots and becomes firm, warm and red; later (about 10 days) it begins to liquefy and becomes fluctuant.

Principles of management

• Explanation and reassurance

• RICE (for larger bruises/haematomas) for 48 hours

  R = Rest

  I = Ice (for 20 minutes every 2 waking hours)

  C = Compression (firm elastic bandage)

  E = Elevation (if a limb)

• Analgesics: paracetamol

• Avoid needle aspiration (some exceptions)

• Avoid massage

• Local heat may be applied after 72 hours

• Consider possibility of bleeding disorder if bleeding is out of proportion to the injury

Some haematomas in certain locations can cause deformity and other problems.

Haematoma of nasal septum¹

Refer CHAPTER 59.

Haematoma of the pinna¹

When trauma to the pinna causes a haematoma between the epidermis and the cartilage, a permanent deformity known as ‘cauliflower ear’ may result. The haematoma, if left, becomes organised and the normal contour of the ear is lost.

The aim is to evacuate the haematoma as soon as practical and then to prevent it reforming. One can achieve a fair degree of success, even on haematomas that have been present for several days.

Method

Under aseptic conditions insert a 25 gauge needle into the haematoma at its lowest point and aspirate the extravasated blood (see FIG. 132.1A). Apply a padded clamp to the haematoma site and leave on for 30–40 minutes (see FIG. 132.1B). Generally, daily aspiration and clamping are sufficient to eradicate the haematoma completely.

Subungual haematomas

These important haematomas are discussed in CHAPTER 127.

Abrasions vary considerably in degree and potential contamination. They are common with bicycle, motorcycle and skateboard accidents. Special care is needed over joints such as the knee or elbow.

Rules of management

• Clean meticulously, remove all ground-in dirt, metal, clothing and other material.

• Scrub out dirt with sterile normal saline under anaesthesia (local infiltration or general anaesthesia for deep wounds).

• Treat the injury similarly to a burn.

• When clean, apply a protective dressing (some wounds may be left open).

• Use paraffin gauze and non-adhesive absorbent pads such as Melolin.

• Ensure adequate follow-up.

• Immobilise a joint that may be affected by a deep wound.

Lacerations vary enormously in complexity and repairability. Very complex lacerations and those involving nerves or other structures should be referred to an expert.

Principles of repair

• Good approximation of wound edges minimises scar formation and healing time.

• Pay special attention to debridement.

• Avoid deep layers of suture material in a contaminated wound—consider drainage.

• Inspect all wounds carefully for damage to major structures such as nerves and tendons and for foreign material:

  • – shattered glass wounds require careful inspection and perhaps plain X-ray or ultrasound

  • – high-energy wounds (e.g. motor mowers) are prone to have metallic foreign bodies and associated fractures

• Consider X-rays of wounds to look for foreign objects or fractures (compound fractures).

• Trim jagged or crushed wound edges, especially on the face.

• All wounds should be closed so that opposite layers line up.

• Avoid leaving dead space.

• Do not suture an ‘old’ wound (greater than 8 hours) if it is contaminated: leave 4 days before suturing (unless infected). You may need to excise a thin section off each edge to obtain a new healing surface.

• Take care in poor healing areas, such as backs, necks, calves and knees, and in areas prone to hypertrophic scarring, such as over the sternum, chest or shoulder.

• Use atraumatic tissue-handling techniques, with minimal handling of wound edges.

• Everted edges heal better than inverted edges.

• A suture is too tight when it blanches the skin between the thread—loosen it.

• Avoid tension on the wound, especially in fingers, lower leg, foot or palm.

• A finer scar and better result is obtained by using a large number of fine sutures rather than fewer thick sutures more widely spread.

• Avoid haematoma.

• Apply a firm pressure dressing when appropriate, especially with swollen skin flaps.

• Consider appropriate immobilisation for wounds. Many wound failures are due to lack of immobilisation from a volar slab on the hand or a back slab on the leg.

Practical aspects

Suture material

See TABLE 132.1.

• Monofilament nylon sutures are generally preferred for skin repair.

• Use the smallest calibre compatible with required strains.

• The synthetic, absorbable polyglycolic acid or polyglactin sutures (Dexon, Vicryl) are stronger than catgut of the same gauge, but are not as suitable as catgut on the face or subcuticularly.

Instruments

Examples of good-quality instruments:

• locking needle holder (e.g. Crile–Wood 12 cm)

• skin hooks

• iris scissors

• toothed forceps

Holding the needle

The needle should be held about two-thirds of the way back from the tip; it can distort if held right near the back end (see FIG. 132.2). Tougher tissues may require grasping the needle at its centre.

Dead space

Dead space should be eliminated to reduce tension on skin sutures. Use buried, absorbable sutures to approximate underlying tissue. This is done by starting suture insertion from the fat to pick up the fat/dermis interface so as to bury the knot (see FIG. 132.3).

Everted wounds

Eversion is achieved by making the ‘bite’ in the dermis wider than the bite in the epidermis (skin surface) and making the suture deeper than it is wide. Shown are:

• simple suture (see FIG. 132.4A)

• vertical mattress suture (see FIG. 132.4B)

The mattress suture is the ideal way to evert a wound.

Number of sutures

One should aim to use a minimum number of sutures to achieve closure without gaps but sufficient sutures to avoid tension. Place the sutures as close to the wound edge as is reasonably possible.

The three-point suture

In wounds with a triangular flap component, it is often difficult to place the apex of the flap accurately. The three-point suture is the best way to achieve this while minimising the chance of strangulation necrosis at the tip of the flap.

Method

1. Pass the needle through the skin of the non-flap side of the wound.

2. Then pass it through the subcuticular layer of the flap tip at exactly the same level as the reception side.

3. Finally, pass the needle back through the reception side so that it emerges well back from the V flap (see FIG. 132.5).

Triangular flap wounds on the lower leg

Triangular flap wounds below the knee are a common injury and are often treated incorrectly. Similar wounds in the upper limb heal rapidly when sutured properly, but lower limb injury will not usually heal at first intention unless the apex of the flap is given special attention.

Proximally based flap

A fall through a gap in floorboards will produce a proximally based flap; a heavy object (such as the tailboard of a trailer) striking the shin will result in a distally based flap.

Often the apex of the flap is crushed and poorly vascularised; it will not survive to heal after suture.

Treatment methods (under infiltration with LA)

1. Preferred method: to attempt to salvage the distal flap, scrape away the subcutaneous tissue on the flap and use it as a full-thickness graft.

2. An alternative is to excise the apex of the flap, loosely suture the remaining flap and place a small split-thickness graft on the raw area (see FIG. 132.6).

For both methods apply a suitable dressing and strap firmly with a crepe bandage. The patient should rest with the leg elevated for 3 days.

Distally based flap

See FIGURE 132.7. This flap, which is quite avascular, has a poorer prognosis. The same methods as for the proximally based flap can be used. Trimming the flap and using it as a full thickness graft has a good chance of repair in a younger person but a poor chance in elderly people.

Repair of cut lip

While small lacerations of the buccal mucosa of the lip can be left safely, more extensive cuts require careful repair. Local anaesthetic infiltration may be adequate, although a mental nerve block is ideal for larger lacerations of the lower lip.

For wounds that cross the vermilion border, meticulous alignment is essential. It may be advisable to pre-mark the vermilion border with gentian violet or a marker pen. It is desirable to have an assistant.

Method

1. Close the deeper muscular layer of the wound using 4/0 CCG. The first suture should carefully appose the mucosal area of the lip, followed by one or two sutures in the remaining layer.

2. Next, insert a 6/0 monofilament nylon suture to bring both ends of the vermilion border together. The slightest step is unacceptable (see FIG. 132.8). This is the key to the procedure.

3. Close the inner buccal mucosa with interrupted 4/0 plain catgut sutures.

4. The outer skin of the lip (above and below the vermilion border) is closed with interrupted nylon sutures.

Post-repair

1. Apply a moisturising lotion (or petroleum jelly) along the lines of the wound.

2. Remove nylon sutures in 3–4 days (in a young person) or 5–6 days (in an older person).

Repair of lacerated eyelid

General points

• Preserve as much tissue as possible.

• Do not shave the eyebrow.

• Do not invert hair-bearing skin into the wound.

• Ensure precise alignment of wound margins.

• Tie suture knots away from the eyeball. If necessary, leave suture ends long and tape the strands away from the eye.

Method

1. Place an intermarginal suture behind the eyelashes if the margin is involved.

2. Repair conjunctiva and tarsus with 6/0 catgut.

3. Then repair skin and muscle (orbicularis oculi) with 6/0 nylon (see FIG. 132.9).

Repair of tongue wound

Wherever possible, it is best to avoid repairs to tongue wounds because these heal rapidly. However, large flap wounds to the tongue on the dorsum or the lateral border may require suturing. The best method is to use buried catgut sutures.

Method

1. Get patient to suck ice for a few minutes, then infiltrate with 1% lignocaine and leave for 5–10 minutes.

2. Use 4/0 or 3/0 catgut sutures to suture the flap to its bed, and bury the sutures (see FIG. 132.10).

It should not be necessary to use surface sutures. If it is, 4/0 silk sutures will suffice.

Instruct the patient to rinse the mouth regularly with salt water until healing is satisfactory.

The amputated finger

In this emergency situation, instruct the patient to place the severed finger directly into a fluid-tight sterile container, such as a plastic bag or sterile specimen jar. Then place this ‘unit’ in a bag containing iced water with crushed ice.

Note: Never place the amputated finger directly in ice or in fluid such as saline. Fluid makes the tissue soggy, rendering microsurgical repair difficult.

Care of the finger stump

Apply a simple, sterile, loose, non-sticky dressing and keep the hand elevated.

Bite wounds

Human bites and clenched fist injuries

Human bites and clenched fist injuries can present a serious problem of infection. Beta-lactamase-producing anaerobic organisms in the oral cavity (e.g. Vincent’s) can penetrate the damaged tissue and form a deep-seated infection. Streptococcus species, staphylococcal organisms and Eikenella corrodens are common pathogens. Complications of the infected wounds include cellulitis, wound abscess and lymphangitis. A Cochrane review of antibiotic prophylaxis concluded that it reduces the risk of infection.²

Principles of treatment

• Clean and debride the wound carefully (e.g. aqueous antiseptic solution or hydrogen peroxide).

• Give prophylactic penicillin if a severe or deep bite.

• Avoid suturing if possible.

• Tetanus toxoid (although minimum risk).

• Consider rare possibility of HIV and hepatitis B or C infections.

• For high-risk wounds, give procaine penicillin 1.5 g IM statim and/or amoxycillin/clavulanate 875/125 mg bd for 5 days.³

• If established infection in a deep wound, take a swab and give metronidazole 400 mg (o) bd for 14 days plus either cefotaxime 1 g IV 8 hourly or ceftriaxone 1 g IV daily for 14 days.

Dog bites

Non-rabid

Dog bites typically have poor healing and carry a risk of infection with anaerobic organisms, including tetanus, staphylococci and streptococci. Puncture and crush wounds are more prone to infection than laceration. Up to 25% of dog bite wounds become infected, with the first signs appearing in about 24 hours.⁴

Principles of treatment (see FIG. 132.11):

• Clean and debride the wound with aqueous antiseptic, allowing it to soak for 10–20 minutes.

• Aim for open healing—avoid suturing if possible (except in ‘privileged’ sites with an excellent blood supply such as the face and scalp).

• Apply non-adherent, absorbent dressings (paraffin gauze and Melolin) to absorb the discharge from the wound.

• Tetanus prophylaxis: immunoglobulin or tetanus toxoid.

• A 2008 Cochrane review found no evidence supporting prophylactic antibiotics for dog or cat bites.² Small wounds presenting within 8 hours that do not involve joints or tendons do not require antibiotics.

• However, for a severe or deep bite, give prophylactic penicillin: 1.5 million units procaine penicillin IM statim, then orally for 5–10 days. An alternative is amoxycillin/clavulanate for 5–7 days. Use this antibiotic for 7–10 days for an established infection (depending on swab).⁴

• Inform the patient that slow healing and scarring are likely.

Rabid or possibly rabid dog (or other animal)

Not currently applicable in Australia (see CHAPTER 15).

• Wash the site immediately with detergent or saline (preferable) or hydrogen peroxide or soap (if no other option).

• Do not suture.

• If rabid:

  • – human rabies immune globulin (passive)

  • – antirabies vaccine (active)

• Uncertain: capture and observe animal, consider vaccination.

Cat bites

Cat bites have the greatest potential for suppurative infection, with Pasteurella multocida being the most common organism. The same principles apply as for the management of human or dog bites. For deep or delayed wounds, use amoxycillin + clavulanate for prophylaxis for 5 days. For infection, swab the wound but start with metronidazole + doxycycline or ciprofloxacin.³ It is important to clean a deep and penetrating wound. Another problem is cat-scratch disease, presumably caused by a Gram-negative bacterium, Bartonella henselae.

Clinical features of cat-scratch disease

• An infected ulcer or papule pustule at bite site (30–50% of cases) after 3 days or so⁵

• 1–3 weeks later: fever, headache, malaise, regional lymphadenopathy (may suppurate)

• Intradermal skin test positive

• Benign, self-limiting course usually not requiring antibiotic treatment

• Sometimes severe symptoms for weeks, especially in immunocompromised

• For lymphadenopathy unresolved after 1 month, or significant morbidity, treat with erythromycin or roxithromycin for 10 days³

Water-related wound infections³

These complex infections may require expert advice.

Coral cuts

Wounds from coral cuts are at risk of serious infection with Vibrio organisms (marine pathogens) or Streptococcus pyogenes. Such wounds require cleaning with antiseptics, debridement, dressing and antibiotic cover with doxycycline 100 mg bd or cephalexin 500 mg bd for 7 days.

Fish tank/swimming pool granuloma

Due to Mycobacterium marinum, which causes a localised papular or nodular skin lesion, usually in people who clean aquaria or swimming pools. Diagnosis is by biopsy and culture (acid-fast bacilli).

Treatment: single lesion excision (may suffice). May need antibiotic therapy e.g. clarithromycin (o) bd for 3–4 months plus rifampicin for severe or unresponsive infection. Seek expert advice.

Aeromonas species wound infections

From fresh or brackish water or mud exposure to open wounds. Treat with ciprofloxacin for 14 days.³

Shewanella putrefaciens

From salt or brackish water, particularly legs with vascular compromise. Causes severe cellulitis with necrosis, even sepsis. Treat with ciprofloxacin or meropenem/imipenem.

If lacerations are small but gaping use the child’s hair for the suture, provided it is long enough.

Method

Make a twisted bunch of the child’s own hair on each side of the wound. Tie a reef knot and then an extra holding knot to minimise slipping. Ask an assistant to drop compound benzoin tincture solution (Friar’s Balsam) on the hair knot. Leave the hair ‘suture’ long and get the parent to cut the knot in 5 days.

Forehead and other lacerations in children

Despite the temptation, avoid using reinforced paper adhesive strips (Steri-Strips) for children with open wounds. They will merely close the dermis and cause a thin, stretched scar. They can be used only for very superficial epidermal wounds in conjunction with sutures.

Adhesive glue for wound adhesion

A tissue adhesive glue can be used successfully to close superficial smooth and clean skin wounds, particularly in children. Commercial preparations such as Histoacryl, Dermabond and Epiglu (active ingredient enbucrilate) are available. SuperGlue also serves the purpose although sterility and toxicity have to be considered. The glue should be used only for superficial, dry, clean and fresh wounds. No gaps are permissible with this method; glue in the wound will block healing. Avoid glues if possible.

Wound anaesthesia in children

Consider topical anaesthetic preparations for wound repair in children. They include lignocaine and prilocaine mixture (EMLA cream) and adrenaline and cocaine (AC) liquid. Use the latter with caution.

Some practitioners use an ice block to freeze the lacerated site, with or without a little lignocaine dripped into the wound. The child is asked to hold the ice while a suture is rapidly inserted.

Suture marks are related to the time of retention of the suture, its tension and position. The objective is to remove the sutures as early as possible, as soon as their purpose is achieved. The timing of removal is based on common sense and individual cases. Silk and other polyfilament sutures are more reactive and should be removed early. After suture removal, it is advisable to support the wound with Micropore skin tape/Steri-Strips for 1–2 weeks, especially in areas of skin tension.

Method

1. Use good light and have the patient lying comfortably.

2. Use fine, sharp scissors that cut to the point, or a disposable suture cutter blade, and a pair of fine, non-toothed dissecting forceps that grip firmly.

3. Cut the suture close to the skin below the knot with scissors or blade (see FIG. 132.12A).

4. Gently pull the suture out towards the side on which it was divided—that is, always towards the wound (see FIG. 132.12B).

When to remove non-absorbable sutures

For removal of sutures after non-complicated wound closure in adults, see TABLE 132.2.

Note: Decisions need to be individualised according to the nature of the wound and health of the patient and healing. In general, take sutures out as soon as possible. One way of achieving this is to remove alternate sutures a day or two earlier and remove the rest at the usual time. Steri-Strips can then be used to maintain closure and healing.

Additional aspects

In children, tend to remove 1–2 days earlier. Allow additional time for backs and legs, especially the calf. Nylon sutures can be left in longer because they are less reactive. Alternate sutures may be removed earlier (e.g. face in women).

Management depends on extent and depth (burns are classified as superficial or deep—otherwise first, second or third degree).

First degree burns are superficial and involve only the epidermis, causing pain, redness and swelling. A scald, which is a burn caused by moist heat, is an example. Healing proceeds quickly.

Second degree or partial skin thickness burns cause the epidermis to blister and become necrotic with subsequent serous ooze.

In third degree or full thickness burns, there is deep necrosis and perhaps anaesthesia from destroyed nerve endings. If extensive (>9% of body surface area) and deep there is a possibility of hypovolaemia and shock.

A major burn, which is a medical emergency, is an injury of more than 20% of the total body surface for an adult and 10% for a child.

First aid

The immediate treatment of burns, especially for smaller areas, is immersion in cool to cold, running water such as tap water, for a minimum of 20 minutes. Do not disturb charred adherent clothing but remove wet clothing.

Chemical burns should be liberally irrigated with water. Apply 1 in 10 diluted vinegar to alkali burns and sodium bicarbonate solution for acid burns.

Refer the following burns to hospital:

• >9% surface area, especially in a child (see ‘rule of nines’, CHAPTER 119) The patient’s hand size equals approximately 1%.⁷

• >5% in an infant

• all deep burns

• burns of difficult or vital areas (e.g. face, hands, perineum/genitalia, feet)

• burns with potential problems (e.g. electrical, chemical, circumferential)

• suspicion of inhalational injury

Always give adequate pain relief. During transport, continue cooling by using a fine-mist water spray.

Treatment

1. Very superficial—intact skin. Can be left with application of a mild antiseptic only (e.g. aqueous chlorhexidine). Review if blistering.

2. Superficial—blistered skin. Apply a dressing to promote epithelialisation (e.g. hydrocolloid sheets, hydrogel sheets) covered by an absorbent dressing or (best option) a retention adhesive material (e.g. Fixomull, Mefix, Hypafix) with daily or twice daily cleaning of the serous ooze and reapplication of outer stretch bandage. Fixomull can be left in place for up to 2 weeks.

Guidelines to patient for retention dressings

• First 24 hours: keep dry. Pat dry any ooze coming through the dressing with a clean tissue.

• From day 2: wash over dressing twice daily. Use gentle soap and water, rinse then pat dry. Do not soak. Rinse only. Do not remove the dressing as it may cause pain and damage to the wound. If the wound becomes red, hot or swollen, or if pain increases, return to the clinic.

• From day 7: return to the clinic for removal of the dressing. Two hours prior to coming into the clinic, soak the dressing with olive oil then cover with cling wrap (e.g. GLAD Wrap).

Note: Dressing must be soaked off with oil (e.g. olive, baby, citrus or peanut). Debride ‘popped blisters’. Only pop blisters that interfere with dermal circulation.

• 3 Deep burns. If considerable ooze, apply the following in order:

  • SoloSite gel, Solugel or similar

  • non-adherent neutral dressing (e.g. Melolin)

  • layer of absorbent gauze or cotton wool (larger burns)

Change every 2–4 days with analgesic cover. Surgical treatment, including skin grafting, may be necessary.

The Alfred Hospital publishes excellent burns guidelines at <www.vicburns.org.au>.

Exposure (open method)

• Keep open without dressings (good for face, perineum or single surface burns)

• Renew coating of antiseptic cream every 24 hours

Dressings (closed method)

• Suitable for circumferential wounds

• Cover area with non-adherent tulle (e.g. paraffin gauze)

• Dress with an absorbent, bulky layer of gauze and wool

• Use a plaster splint if necessary

Burns to hands

For superficial blistered burns to the hand or similar ‘complex’ shaped parts of the body apply strips of the retention stretch adhesive dressings as described above. They conform well to digits. Apply an outer bandage. At 7 days, soak the dressings in oil for 2 hours prior to coming in to the clinic.

Penetrating gun injuries

Injuries to the body from various types of guns present decision dilemmas for the treating doctor. The following information represents guidelines, including special sources of danger to tissues from various foreign materials discharged by guns.

Gunshot wounds

Airgun

The rule is to remove subcutaneous slugs but to leave deeper slugs unless they lie within and around vital structures (e.g. the wrist). A special common problem is that of slugs in the orbit. These often do little damage and the ophthalmologist may decide to leave them alone.

0.22 rifle (the pea rifle)

The same principles of management apply but the bullet must be localised precisely by X-ray. Of particular interest are abdominal wounds, which should be observed carefully, as visceral perforations can occur with minimal initial symptoms and signs.

0.410 shotgun

The pellets from this shotgun are usually dangerous only when penetrating from a close range. Again, the rule is not to remove deep-lying pellets—perhaps only those superficial pellets that can be palpated.

Pressure gun injuries

Injection of grease, oil, paint and similar substances from pressure guns (see FIG. 132.13) can cause very serious injuries, requiring decompression and removal of the substances.

Grease gun and paint gun

High-pressure injection of paint or grease into the hand requires urgent surgery if amputation is to be avoided. There is a deceptively minor wound to show for this injury, and after a while the hand feels comfortable. However, ischaemia,¹ chemical irritation and infection can follow, with gangrene of the digits, resulting in, at best, a claw hand due to sclerosis. Treatment is by immediate decompression and meticulous removal of all foreign material and necrotic tissue.

Oil injection

Accidental injection of an inoculum in an oily vehicle into the hand also creates a serious problem with local tissue necrosis. Such injections are common on poultry farms during fowl-pest injections. If injected into the digital pulp, this may necessitate amputation.

Splinters under the skin

The splinter under the skin is a common and difficult procedural problem. Instead of using forceps or making a wider excision, use a disposable hypodermic needle to ‘spear’ the splinter (see FIG. 132.14) and then use it as a lever to ease the splinter out through the skin.

A ‘buried’ wooden foreign body can be detected by ultrasound.

Embedded fish hooks

Two methods of removing fish hooks are presented here, both requiring removal in the reverse direction, against the barb. Method 2 is recommended as first-line management.

Method 1

1. Inject 1–2 mL of LA around the fish hook.

2. Grasp the shank of the hook with strong artery forceps.

3. Slide a D11 scalpel blade in along the hook, sharp edge away from the hook, to cut the tissue and free the barb (see FIG. 132.15).

4. Withdraw the hook with the forceps.

Method 2

This method, used by some brave fishermen, relies on a loop of cord or fishing line to forcibly disengage and extract the hook intact. It requires no anaesthesia and no instruments—only nerves of steel, especially for the first attempt.

1. Take a piece of string about 10–12 cm long and make a loop. One end slips around the hook, the other hooking around one finger of the operator.

2. Depress the shank with the other hand in the direction that tends to disengage the barb.

3. At this point give a very swift, sharp tug along the cord.

4. The hook flies out painlessly in the direction of the tug (see FIG. 132.16). Wear safety goggles!

Note: You must be bold, decisive, confident and quick—half-hearted attempts do not work.

For difficult cases, some local anaesthetic infiltration may be appropriate. Instead of a short loop of cord, a long piece of fishing line double looped around the hook and tugged by the hand, or flicked with a thin ruler in the loop, will work.

Accidental skin puncture by contaminated ‘sharps’, including needles (with blood or bloodstained body fluids), is of great concern to all health care workers. Another problem that occurs occasionally is the deliberate inoculation of people such as police by angry, sociopathic individuals. A needle-stick accident is the commonest incident with the potential to transmit infections such as HIV and hepatitis B, C or D. The part of the venipuncture that is most likely to cause the accident is the recapping or resheathing of the needle. This practice should be discouraged.

Infections transmitted by needle-stick accidents are summarised in TABLE 132.3. The risk from a contaminated patient is greatest with hepatitis (10–30%), while the risk of seroconversion or clinical infection after a needle-stick injury with HIV-positive blood is very low (probably about 1 in 300).⁸ In children injured by needle stick incidentally in the community (e.g. at the beach or park), there are no published reports of transmission of a blood-borne virus such as HIV or hepatitis B or C.⁹ The risk of tetanus, especially for outdoor injuries, is significant and should be addressed.

Prevention

• Avoid physically struggling with overdose victims or high-risk patients for lavage or venipuncture.

• Do not recap needles.

• Dispose of needles immediately and directly into a leak-proof, puncture-proof sharps container.

• Avoid contact with blood.

• Wear protective gloves (does not prevent sharps injury).

Postexposure prophylaxis

Postexposure prophylaxis (PEP) must be considered for high-risk exposure such as hollow blood-containing needles, deep injury and high viral load or late-stage HIV infection of the source.³ Although in most instances of sharps injuries PEP is not justified, do seek expert advice.

Management¹⁰

• Wash affected site with soap and water without scrubbing. Also wash or irrigate any areas of skin, eye/conjectiva or other mucous membrane exposed to blood or body fluids.

• Do not suck or squeeze wound.

• Encourage bleeding.

• Reassure the patient that the risk of viral infection is very low.

• Obtain information about and blood from the sharps victim and the source person (source of body fluid). A known carrier of hepatitis B surface antigen or an HIV-positive source person will facilitate early decision making.

Note: It takes 3 months to seroconvert with HIV so the patient may be infected but negative on initial tests.

Consider the exposed person’s wishes after discussing the risks/benefits of treatment including adverse effects.

Known hepatitis B carrier source person

• If injured person is immune—no further action

• If non-vaccinated and non-immune:

  • – give hyperimmune hepatitis B gammaglobulin within 48 hours

  • – commence course of hepatitis B vaccination within 24 hours

Known hepatitis C carrier source person¹⁰

• The recipient needs to have follow-up HCV antibody tests at 1 and 6 weeks and ALT levels at 4–6 months.

• There is no effective immunoprophylaxis available. Consider early therapy should seroconversion occur.

Known HIV-positive source person¹⁰

Refer to consultant about relative merits of drug prophylaxis (ART) and serological monitoring. A case control study by the US Centers for Disease Control and Prevention indicated that giving zidovudine following a needle-stick injury decreases the rate of HIV seroconversion by 79%.¹¹

HIV postexposure prophylaxis consists of 2–3 anti-retroviral medications administered for 28 days. Seek advice urgently, because prophylaxis is ideally commenced within 2 hours of exposure.

Unknown risk source person

Take source person’s blood (if consent is given) and sharps victim’s blood for hepatitis B (HBsAg and anti-HBs) and hepatitis C and HIV status tests. Commence hepatitis B vaccination if not vaccinated.

Note: Informed consent for testing and disclosure of test results for involved person should be obtained.

Tetanus is a very serious disease but completely preventable by active immunisation. Immunisation should be universal, as per the childhood and adult immunisation program. However, all patients with wounds should be assessed for their tetanus status and managed on their merits. For severe wounds, the possibility of gas gangrene should also be considered.

Tetanus-prone wounds:

• compound fractures

• penetrating injuries

• foreign bodies

• extensive crushing

• delayed debridement

• severe burns

• pyogenic infection

For the primary immunisation of adults, tetanus toxoid (available combined with diphtheria and, often, pertussis) is given as two doses 6 weeks apart, with a third dose 6 months later. Booster doses of tetanus toxoid are given as an adolescent and at age 50. Give a booster dose at the time of major injury unless it is less than 5 years since the previous dose.¹²

Passive immunisation

Passive immunisation, in the form of tetanus immunoglobulin 250 units by IM injection, is reserved for non-immunised individuals or those of uncertain immunity wherever the wound is contaminated or has devitalised tissue. It should be given as soon as possible, on the day of injury. Wounds at risk include those contaminated with dirt, faeces/manure, soil, saliva or other foreign material; puncture wounds; and wounds from missiles, crushes and burns.

The guide is outlined in TABLE 132.4.