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Penetrating extremity trauma

Roy Danks roydanks at hotmail.com
Fri Apr 21 14:13:13 BST 2006

 It was stated: "Standard of care depends on the mechanism of injury and the nature of the wound": 

DISAGREE.  Penetrating injuries, whether low velocity or high, are at risk for vascular injury.
Work them up, initially, in the same way:  Physical exam, looking for hard signs of vascular injury, ABIs looking for discrepencies in flow and neuro exam looking for nerve injury.
ABIs don't tell all:  there might be a major vein injury, well hidden in the recesses of the popliteal fossa, etc.  Just this week, I took care of a young man with
a penetrating injury to the thigh caused by a pneumatic nail gun.  3 inch nail, almost protruding from the popliteal fossa.  It entered the ant thigh.  I explored the wound
for the purpose of removing the nail.  The nail had penetrated the anterior and posterior walls of the popliteal vein and caused damage to the tibial nerve.  That's about 
as low velocity as you can get, sans a BB (not pellet) gun injury.

Hard signs?  Go to OR.  Soft signs?  Watch them.  No signs?  Send them home.

Don't get caught up in this myth that "low velocity" wounds are low risk wounds.  That's bunk.  Yes, they tend to cause LESS collateral damage, but they still
cause arterial, venous and nerve injury.  You must rule these out.

 It was stated: "Certain stab and hand gun wounds (low velocity) with low probabilty for vascular injury we give a dose of prophylactic A/Bs IV and 
send them hope on oral A/Bs to f/u in the surgery clinic." 

 NO:  First, the injury has occurred, so they're not "Prophylactic", they are 
"Presumptive".  I don't believe there is ANY evidence to suggest this is beneficial.  It's like giving ABX after skin incision in the OR.  You've already 
created the "injury", giving the ABX later won't benefit the pt.  Burns are the same way.  There is no role for "Prophylactic/Presumptive" ABX in burns.
This is shown in at least one well controlled study.  Will it hurt to give a dose?  Unlikely.  Will it prevent an infection?  Also unlikely.

I would recommend the interested reader go to www.east.org and review the practice guideline for penetrating extremity injury.

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