Injuries — soft tissue

Necrotising fasciitis

• Rapidly progressive soft tissue infection — life threatening  — urgent medical consult 
  
• Often mismatch between the patient’s appearance and what is visible
• Pain that is far more severe than expected for what is seen 
• OR severe soft tissue infection with minimal pain (nerves damaged)

Ask

• If person has history of RHD, endocarditis, artificial heart valves — see Prevention of endocarditis

Check

• Head-to-toe exam — with attention to
• Involving hand, neck, armpit or groin
• Neurovascular, tendon, joint or bone involvement
• Risk of penetrating a body cavity — head, chest, abdomen, buttocks, close to hip or shoulder
• Crush injury or extensive tissue damage
• Nerve injury — numbness
• Contamination — carefully check wound for foreign bodies
• Infection — localised or systemic features, sepsis
• Immunisation status — tetanus

Do

• Clean wound, irrigate with normal saline 
• If wound very dirty or dead tissue present — medical consult
• If wound infected or not improving with antibiotics — swab wound 
• If wound needs to be debrided or gently scrubbed to remove dirt — consider local anaesthetic
• Lidocaine (lignocaine) 1% injection — up to 0.3mL/kg
• Lidocaine-prilocaine (lignocaine-prilocaine) cream OR gauze soaked in lidocaine (lignocaine) 2%
• Takes about 30 minutes to work
• Give pain relief — back slab often useful
• If object sticking into body — medical consult 
• If puncture wound to the sole of foot through footwear — medical consult
• If injury to finger needs sutures or closer examination — may need nerve block
• If infection doesn’t get better or gets worse — medical consult

Injuries less than 8 hours old and clean

Complicated injuries — tendon, joint or bone involvement

Severe injuries — crush injury or extensive tissue damage

• If complicated or severe OR appears infected 
• Do not close
• Give antibiotics — Table 2.15  OR if significant fresh or salt water exposure — see Water-related skin infections
• Medical consult  to consider sending to hospital
• If not complicated and not severe — see Examining and cleaning a wound before closing

Injuries less than 8 hours old and dirty OR more than 8 hours old

• Give antibiotics — Table 2.15 OR if significant fresh or salt water exposure — see Water-related skin infections
• If complicated or severe — medical consult
• If not complicated and not severe
  
• Clean with normal saline 
• Debride (cut away dead and badly damaged tissue), trim wound edge
• If less than 8 hours old and now clean — close
• If less than 8 hours old and still not clean OR more than 8 hours old — medical consult
• Do not close, dress wound daily