Injury to internal organs.
Wounds such as stab wounds may be associated with damage to internal organs. Treatment of penetrating abdominal or thoracic wounds has been discussed elsewhere. The possibility of blunt or sharp abdominal trauma must not be overlooked when treating extensive injuries elsewhere, particularly in an unconscious patient.
War wounds and gunshot injuries
Gunshot injuries are associated with different severity of tissue damage depending upon whether the injury is of low or high velocity. Low-velocity injuries, such as from a hand gun, result in an entry and exit wound, the latter being the larger, and damage along the tract of the missile. Such injuries are often associated with severe tissue contamination from clothing, dirt or other foreign materials. High-velocity injuries (from modern assault rifles) cause explosive pressure and decom
pression effect, such that there is widespread tissue damage, with injury to major limb vessels and nerves situated some distance from the tract of the missile. Where a high-velocity missile strikes bone, the high-energy exchange results in fragmentation of the bone. Gunshot wounds and war wounds require careful surgical excision and such wounds should be left open. Following high-velocity injuries, fasciotomy of all of the fascial compartments of the limb should be undertaken. The damage from a shotgun wound depends on the scatter of the shot and therefore on the range. A large track of damage may result in severe bleeding or a pneumothorax, which requires immediate appropriate emergency management.
Injuries to bone and joints
Fractures may be closed where the skin is intact or open where there is a wound. Open fractures may have a skin wound due to penetration from the outside or, more frequently, due to bursting of the skin from within by bone fragments. The bone displacement is worst at the very moment of injury and bone fragments partially reduce spontaneously thereafter. It is important to appreciate that a puncture wound of the skin overlying a fracture is almost certainly evidence that the skin was penetrated by bone. The usual principles of wound management apply in that an adequate excision of the wound is necessary followed by antibiotic treatment and appropriate treatment of the fracture. Severe open lower limb injuries often have extensive damage to the skin and muscle in addition to fractures. It is best to treat the fracture and soft-tissue injuries simultaneously. Extensive removal of damaged soft tissue may be required and skin cover achieved by a one-stage microvascular tissue transfer.
Injury to nerves
Glass does not bruise nerves. Where there is an open wound, nerve division must always be suspected. Clinical examination should be undertaken to assess the motor and sensory function of every nerve in the region of the open wound, and it must be assumed that an underlying nerve has been divided until its function can be demonstrated to be intact. A sharp, wounding implement can travel a considerable distance in the soft tissues, and with limb injuries it is necessary to assess all the major nerve trunks at that level in the limb. Where there is doubt the nerve should be explored and visualised. Divided nerves should be repaired. Magnification and fine suture materials have improved results.
Injuries to arteries and veins
Where a wound is associated with much bleeding there is the possibility that a significantly large vessel has been divided. As a first aid measure, bleeding will almost always be controlled by direct pressure, and elevation of the part where practicable. Limb tourniquets should not be applied as a first aid measure. In the emergency department it is never desirable to plunge vascular damps or artery forceps into a wound without a proper view of the bleeding point, as graspingnerves can inflict great harm. Where a major limb vessel has been damaged it may be necessary to apply direct manual pressure while the patient is taken into an operating room. Under anaesthesia, the appropriate way to deal with bleeding in the limb is to explore the wound under pneumatic tourniquet control.
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