Rosen & Barkin's 5-Minute Emergency Medicine Consult (415 page)

• See “Conscious Sedation.”
  
• Tetanus (Tdap/Td for adolescents–adults, DTap for peds): 0.5 mL IM
  
• Local anesthetics:
  
  • Topical, applied directly to wound with cotton, gauze:
    
    • EMLA (eutectic mixture, 5% lidocaine, and prilocaine): Apply for 60 min. Note: each g of EMLA contains 2.5 g of lidocaine, do not exceed 3 mg/kg lidocaine
      
    • TAC (0.5% tetracaine, 1:2,000 adrenaline, 11.8% cocaine): Apply for 20–30 min. Apply from 2–5 mL to wound
      
    • LET (4% lidocaine, 1:1,000 epinephrine, 0.5% tetracaine): Apply for 20–30 min. Apply 1–3 mL. Do not exceed 3 mg/kg lidocaine.
      
• Injected:
  
  • Bupivacaine (max.: 2 mg/kg; duration 3–10 hr)
    
  • Lidocaine (max.: 4.5 mg/kg; duration 1.5–3.5 hr)
    
• Suture materials:
  
  • Absorbable:
    
    • For use in mucous membranes and buried muscle/fascial layer closures
      
    • Natural: Dissolve <1 wk, poor tensile strength, local inflammation: Plain gut, chromic gut, fast-absorbing gut (for certain facial lacerations where cosmesis is important)
      
    • Synthetic braided: Tensile strength diminishing over 1 mo, mild inflammation: Polyglycolic acid (Dexon), polyglactin 910 (Vicryl)
      
    • Synthetic monofilament: Tensile strength 70% at 1 mo: Polydioxanone (PDS), polyglyconate (Maxon)
      
  • Nonabsorbable:
    
    • Greatest tensile strength
      
    • Monofilament: Nylon (Ethilon, Dermalon), polypropylene (Prolene), polybutester (Novafil) can stretch with wound edema, polyethylene (stainless steel)
      
    • Multifilament: Cotton, Dacron, silk (local inflammation)
      
  • Needle types:
    
    • Cutting (cuticular and plastic) types are most often used in outpatient wound repair.
      
• Staples:
  
  • For linear lacerations of scalp, torso, extremities
    
  • Avoid in hands, face, and areas requiring CT or MRI.
    
• Adhesive tapes (Steri-Strips):
  
  • For lacerations that are clean, small, and under minimal tension
    
  • Avoid in wounds that have potential to become very swollen.
    
  • Pretreat wound edges with tincture of benzoin to improve adhesion.
    
• Tissue adhesives:
  
  • Good cosmetic results have been achieved in simple lacerations with low skin tension.
    
  • An alternative to sutures/staples, especially in children
    

FOLLOW-UP

• Few lacerations by themselves necessitate admission unless they require significant debridement or ongoing IV antibiotics, or are complicated by extensive wound care issues or comorbid processes (head injury, abdominal trauma).
  
• It is unsafe for a child to return home when nonaccidental trauma is suspected.
  

• Wounds at risk for infection or poor healing require a wound check within 48 hr.
  
• Time of suture removal dependent on location and peripheral perfusion:
  
  • Scalp: 7–10 days
    
  • Face: 3–5 days
    
  • Oral: 7 days
    
  • Neck: 4–6 days
    
  • Abdomen, back, chest, hands, feet: 7–10 days
    
  • Upper extremity: 7–10 days
    
  • Lower extremity: 10–14 days
    
  • Overlying joints: 10–14 days
    

• Lacerations of the eye where tear duct injury is suspected require immediate referral.
  
• Complicated lacerations (tendon involvement) may require further repair in the outpatient surgical office.
  
• Be sure to discuss temporary skin closure and splinting with your surgical consultant.
  
• Specific follow-up should be arranged prior to patient discharge.
  

• Beam JW. Tissue adhesives for simple traumatic lacerations.
  J Athl Train
  . 2008;43(2):222–224.
  
• Chisolm C, Howell JM. Soft tissue emergencies.
  Emerg Med Clin North Am
  . 1992;10(4):665–705.
  
• Hollander JE, Singer AJ. Laceration management.
  Ann Emerg Med
  . 1999;34(3):356–367.
  
• Roberts PA, Lamacraft G. Techniques to reduce the discomfort of paediatric laceration repair.
  Med J Aust.
  1996;164(1):32–35.
  
• Trott A.
  Wounds and Lacerations: Emergency Care and Closure
  . 4th ed. Philadelphia, PA: Saunders, Elsevier; 2012.
  

See Also (Topic, Algorithm, Electronic Media Element)

Hand Infection

CODES

• 879.8 Open wound(s) (multiple) of unspecified site(s), without mention of complication
  
• 882.0 Open wound of hand except finger(s) alone, without mention of complication
  
• 883.0 Open wound of finger(s), without mention of complication
  

BASICS

• Inflammation of the mucosa of the larynx
  
• The most common cause is viral upper respiratory infection
  
• Peaks parallel epidemics of individual viruses
  
• Most common during late fall, winter, early spring
  

• Viral upper respiratory infections most common in acute laryngitis:
  
  • Influenza A and B
    
  • Parainfluenza types 1 and 2
    
  • Adenovirus
    
  • Coronavirus
    
  • Coxsackievirus
    
  • Respiratory syncytial virus
    
  • Measles
    
  • Rhinovirus
    
• Bacterial infections much less common:
  
  • β-Hemolytic streptococcus
    
  • Streptococcus pneumoniae
    
  • Haemophilus influenzae
    (HiB)
    
  • Moraxella catarrhalis
    
  • Bordetella pertussis
    
  • Diphtheria
    
  • Tuberculosis
    
  • Syphilis
    
  • Leprosy
    
• Laryngopharyngeal reflux (LPR) from gastroesophageal reflux disease (GERD) (especially in adults)
  
• Fungal infections (often associated with inhaled steroid use or immunocompromise)
  
• Allergic
  
• Voice abuse or misuse
  
• Inhalation or ingestion of caustic substances or other irritants
  
• Autoimmune (rheumatoid arthritis, relapsing polychondritis, Wegener granulomatosis, or sarcoidosis)
  
• Trauma
  
• Idiopathic
  

• Acute spasmodic laryngitis (spasmodic croup)
  
• More likely to be infectious.
  
  • Consider HiB, diphtheria, etc., if not immunized
    
• Consider foreign body
  

DIAGNOSIS

• Hoarseness
  
• Abnormal-sounding voice
  
• Throat swelling
  
• Throat tickling
  
• Feeling of throat rawness
  
• Constant urge to clear the throat
  
• Cough
  
• Fever
  
• Malaise
  
• Dysphagia
  

• Regional lymphadenopathy
  
• Stridor in infants
  
• Hoarse voice
  
• Pharyngeal erythema, exudates, and/or edema
  
• Asymmetrical breath sounds in case of foreign body
  

• Acute laryngitis:
  
  • In most cases, the history and inspection of the throat suffice to distinguish between infectious and noninfectious laryngitis:
    
    • Infectious laryngitis usually lasts about 7–10 days.
      
  • Have increased suspicion for epiglottitis in persons who have not had HiB vaccine
    
• Chronic laryngitis (>3 wk):
  
  • The workup should be directed toward chronic infections, GERD, neurologic disorders, and tumors
    
  • Visualization of the larynx should be performed but may not need to be done in the ED
    
  • The patient should be referred to an ear–nose–throat specialist for further workup