Tag Archives: laceration

General

How To: Stop Scalp Bleeding

Leave a comment

Bleeding from scalp wounds may seem like a trivial problem, but I have personally seen someone die from unrecognized hemorrhage over time from one. All too often, these are covered up with a crude dressing when the patient arrives in the ED and is not looked at for some time.

Here are some tips to stop scalp bleeding:

  • Use direct pressure. This seems obvious but is frequently done incorrectly. Direct pressure involves a small diameter piece of gauze (stack of 2x2s or double folded 4×4) and only one or two fingers. Larger dressings or the palm of the hand do not provide enough pressure to stop all the bleeding. Direct pressure for 5 minutes (no peeking) will stop all bleeding that doesn’t need more advanced techniques.
  • Inject local anesthetic with epinephrine. This increases vasoconstriction and helps the direct pressure work even better. Be cautious if there is a large skin flap that does not have a nice pink color. Degloved skin has been crushed and small vessel vascular injury has occurred. Further reducing blood flow with epinephrine may kill the skin flap in this type of injury.
  • Apply Raney clips. Neurosurgeons use these to stop scalp bleeding during brain procedures. Caution! Only apply to unconscious patients, and only to the scalp (not face)! These hurt!
    Raney clips
  • Oversew the scalp. Use a large silk or nylon suture and insert a large running stitch to close the wound. This will stop all bleeding from the skin edges. However, any arterial bleeders underneath will continue to be a problem.
  • Ligate individual bleeders. Use a small absorbable suture and attack each small arterial bleeder with a figure of 8 stitch. Don’t suture large chunks of tissue; make sure that you are attacking just the artery and not any adjacent nerves.
General

Which Lacerations Can I Close?

Leave a comment

There is always debate about which lacerations can be closed, but not a lot of literature to back it up. Here are some good rules to follow:

  • In general, close all face and scalp lacerations. They almost never get infected. Complicated ones may need extra care, debridement, or involvement of a plastic surgeon. 
  • Closing lacerations that are more than 24 hours old is risky (except for the face). They tend to be colonized with skin flora and become infected much more frequently.
  • Most other lacerations can be closed primarily within 24 hours. For the most part, it doesn’t matter what the cutting instrument was. One exception is an object that is heavily contaminated (e.g. freshly used pitchfork). Most knives don’t fall into this category. They are clean, but not sterile and the risk of infection is low.

All wounds should be inspected for foreign bodies. On occasion, this may require an xray. But remember that many foreign objects (wood, glass) are not radiopaque and will be invisible. Next, the wound should be copiously irrigated with sterile saline to flush out any small particles and reduce bacterial counts. Finally, if the edges are ragged the wound should be sharply debrided.

Antibiotics are not usually needed, since the few bacteria left will be rapidly taken care of by the patient’s immune system. If there are worries about contamination or the patient is immunocompromised, a very brief course of antibiotic is recommended. Tetanus toxoid should be given if indicated.

The most important issue is patient education. The signs and symptoms of early wound infection should be explained, and a phone number or location for followup should be clearly listed.

Bottom line: All lacerations can be safely closed within 24 hours, with a few exceptions. 

General

How To: Stop Scalp Bleeding

Leave a comment

Bleeding from scalp wounds may seem like a trivial problem, but I have personally seen someone die from unrecognized hemorrhage over time from one. All too often, these are covered up with a crude dressing when the patient arrives in the ED and is not looked at for some time.

Here are some tips to stop scalp bleeding:

  • Use direct pressure. This seems obvious but is frequently done incorrectly. Direct pressure involves a small diameter piece of gauze (stack of 2x2s or double folded 4×4) and only one or two fingers. Larger dressings or the palm of the hand do not provide enough pressure to stop all the bleeding. Direct pressure for 5 minutes (no peeking) will stop all bleeding that doesn’t need more advanced techniques.
  • Inject local anesthetic with epinephrine. This increases vasoconstriction and helps the direct pressure work even better. Be cautious if there is a large skin flap that does not have a nice pink color. Degloved skin has been crushed and small vessel vascular injury has occurred. Further reducing blood flow with epinephrine may kill the skin flap in this type of injury.
  • Apply Raney clips. Neurosurgeons use these to stop scalp bleeding during brain procedures. Caution! Only apply to unconscious patients, and only to the scalp (not face)! These hurt!
    Raney clips
  • Oversew the scalp. Use a large silk or nylon suture and insert a large running stitch to close the wound. This will stop all bleeding from the skin edges. However, any arterial bleeders underneath will continue to be a problem.
  • Ligate individual bleeders. Use a small absorbable suture and attack each small arterial bleeder with a figure of 8 stitch. Don’t suture large chunks of tissue; make sure that you are attacking just the artery and not any adjacent nerves.