6. Clorhexidina
6.9 Medios de presentación
All patients with traumatic wounds should have ED or private physician follow-up within 48 hours to examine the wound for infection. Tetanus toxoid status should be updated, as is required for any wound.
Antibiotic Use
Clean, uncontaminated wounds that are thoroughly explored, irrigated, and debrided usually do not require antibiotics, although some authors ( 43) recommend the cephalosporin antibiotic cefoperazone (which has antimicrobial activity against Pseudomonas, streptococci, and staphylococci) after puncture wounds of the foot. Antibiotics, however, are not substitute for complete removal of the foreign body and scrupulous attention to wound care (exploration, high-pressure irrigation, debridement, appropriate closure or open wound treatment, and splinting if required).
Antibiotics should be administered to the following patients with soft-tissue lacerations: those at risk for the development of endocarditis ( 44), those with total-knee arthroplasties (45), and those with lymphedema (46). In patients with joint arthroplasties or who are at risk for developing endocarditis, physicians should follow the guidelines published by the American Heart Association for the prevention of endocarditis provided elsewhere in this text. Antibiotics might also be indicated in patients who have wounds with the following characteristics: significant risk of infection (wound contamination with soil, saliva, feces, or vaginal secretions) ( 37), wounds on the foot (37), stellate lacerations with abrasions (47), wounds with associated soft-tissue crush injury (47), tissue injury that might be extensive but difficult to determine during the initial visit (37), lacerations longer than 5 cm (37), impaired wound healing ability (caused by alcoholism (48), chronic renal failure (49), diabetes (50), peripheral vascular disease (51), or malnutrition (51). Additional evidence that supports the use of prophylactic antibiotics is a study of perioperative antibiotics used to prevent infection after elective operations that have a high rate of infection secondary to contamination by skin flora and environmental organisms (52). Patients given a single dose of cefonicid, 1 g intravenously, one half hour before surgery had significantly fewer postoperative wound infections and significantly fewer complications of wound healing (52).
Patients who are candidates for prophylactic antibiotic administration should receive intravenously administered broad-spectrum antibiotics before wound closure to ensure that antibiotics are present in tissue fluid when the wound is manipulated (37). Controlled studies have not revealed the superiority of a single prophylactic antibiotic for all the conditions previously noted. Thus, a reasonable recommendation, based on the author's experience, is to use intravenously administered
cefazolin, 1 g, or vancomycin for patients allergic to cephalosporins. Contaminated wounds should be treated by open-wound management techniques along with the administration of broad-spectrum antibiotics (37). These patients may also benefit from splinting if an extremity is the site of wounding.
References
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2. Jennings TA, Peterson L, Axiotis CA, et al: Angiosarcoma associated with foreign body material. Cancer 1988;62:2436. 3. Iwatsu T, Miyaji M: Phaeomycotic cyst. A case with a lesion containing a wooden splinter. Arch Dermatol 1984;120:1209. 4. Schleicher SM: Stump the experts. J Dermatol Surg Oncol 1987;13:1075.
5. Windler EC, Smith RB, Bryan WJ, et al: Lead intoxication and traumatic arthritis of the hip secondary to retained bullet fragments. J Bone Joint Surg 1978;60A:254. 6. Greene WB: Unrecognized foreign body as a focus for delayed Serratia marcesens osteomyelitis and septic arthritis. J Bone Joint Surg 1989;71A:754.
7. Merrell JC, Russell RC, Zook EG: Nonsuppurative tenosynovitis secondary to foreign body migration. J Hand Surg 1983;8:340. 8. Jablon M, Rabin SI: Late flexor pollicis longus tendon rupture due to retained glass fragments. J Hand Surg 1988;13A:713. 9. Dunn JD: Foresight. High-risk loss prevention. ACEP News 1986.
9A. Roberts J. Retained foreign bodies in ED wounds. Emerg Med News 1997;11:4–10. 10. Meddleton DB: Tricks of the trade. Emerg Med 1996;28:49.
11. Phillips D, Wallings AD: An unusual cause of hip pain in a child. Postgrad Med 1988;84:56.
12. Edlich RF, Kenney JG, Morgan RF, et al: Antimicrobial treatment of minor soft tissue lacerations: a critical review. Emerg Med Clin North Am 1986;4:561. 13. Wade PJF: Penetrating injury of the thigh: a missed radiological diagnosis. Injury 1985;16:568.
14. Marquis GP: Radiolucent foreign bodies in the hand: case report. J Trauma 1989;29:403. 15. Chow J: Foreign body migration in the hand. J Hand Surg 1988;13:462 (letter).
16. Langsam A: Solid foreign bodies in the soft tissue: diagnosis and management. Del Med J 1985;57:693. 17. Tandberg D: Glass in the hand and foot. Will an x-ray film show it? JAMA 1982;248:1872.
18. DeLacey G, Evans R, Sandin B: Penetrating injuries: how easy is it to see glass (and plastic) on radiographs? Br J Radiol 1985;58:27.
19. DeFlavis L, Scaglione P, Del Bo P: Detection of foreign bodies in soft tissue: Experimental comparison of ultrasonography and xeroradiography. J Trauma 1988;28:400. 20. Oesterling JE, Bromberg WD, Albertsen PC: Xeroradiography and ultrasonography in the evaluation of a penile injury. J Urol 1986;135:791.
21. Kuhns LR, Borlaza GS, Seigel RS, et al: An in vitro comparison of computed tomography, xeroradiography, and radiology in the detection of soft-tissue foreign bodies. Radiology 1979;132:218. 22. Carneiro RS, Okunski WJ, Hefferman AW: Detection of a relatively radiolucent foreign body in the hand by xerography. Plast Reconstr Surg 1977;59:862.
23. Stair TO: Xeroradiography and foreign bodies. Am J Emerg Med 1983;1:117.
24. Gooding GAW, Hardiman T, Sumers M, et al: Sonography of the hand and foot in foreign body detection. J Ultrasound Med 1987;6:641. 25. Fornage BD, Schernberg FL: Sonographic diagnosis of foreign bodies of the distal extremities. Am J Roentgenol 1986;147:567.
26. Manthey DE, Storrow AB, Milbourn JM, et al: Ultrasound versus radiography in the detection of soft tissue foreign bodies. Ann Emerg Med 1996;28:7–9. 27. Kirks DR, Harwood-Nash DCF: Computed tomography in pediatric radiology. Pediatr Ann 1980;9:66.
28. Bauer AR, Yutani D: Computed tomographic localization of wooden foreign bodies in children's extremities. Arch Surg 1983;118:1084.
29. Rhoades CE, Soge I, Levine E, et al: Detection of a wooden foreign body in the hand using computed tomography: case report. J Hand Surg 1982;7:306. 30. Haaga JR, Stewart BH, Alfidi RJ: Foreign body localization and removal utilizing computerized axial tomography. Urology 1978;11:306.
31. Klein B, McGahan JP: Thorn synovitis: case report. J Comput Assist. Tomogr 1985;9:1135.
32. Bodine D, Quinn SF, Cochran CF: Imaging foreign glass and wooden bodies of the extremities with CT and MR. J Comput Assist Tomogr 1988;12:608. 33. Smoot EC, Robson MC: Acute management of foreign body injuries of the hand. Ann Emerg Med 1983;17:434.
34. Lindsey D, Lindsey WE: Cactus spine injuries. Am J Emerg Med 1988;6:362. 35. Lammers RL: Soft-tissue foreign bodies. Ann Emerg Med 1988;17:125.
36. Haury BB, Rodeheaver GT, Pettry D, et al: Inhibition of nonspecific defenses by soil infection potentiating factors. Surg Gynecol Obstet 1977;144:19. 37. Edlich RF, Rodeheaver GT, Morgan RF, et al: Principles of emergency wound management. Ann Emerg Med 1988;17:55.
38. Rachman R: Soft-tissue injury by mercury from a broken thermometer. Am J Clin Pathol 1974;61:296.
39. Gahlos F, Arons MS: Soft-tissue foreign body removal: management and presentation of a new technique. J Trauma 1984;24:340. 40. Gilsdorf JR: A needle in the sole of the foot. Surg Gynecol Obstet 1986;163:573.
41. Simmons DP, MacAusland WR, Jr: Trauma to the extremities and soft tissues. In: Schwartz G, Safer P, Stone JH, et al., eds. Principles and Practice of Emergency Medicine. 2nd ed. Philadelphia, PA, WB Saunders, 1986;1437–1441.
42. Edlich RF, Silloway KA, Rodeheaver GT, et al: Industrial nail gun injuries. Compr Ther 1986;12:42. 43. Edlich RF, Morgan RF, Edlich HS, et al: Puncture wounds. Curr Concepts Wound Care 1987;10:11. 44. Kaplan EL, Anthony BF, Bison A, et al: Prevention of endocarditis. Circulation 1977;56:139A.
45. Ahlberg A, Carlsson AS, Lindberg L: Hematogenous infection in total joint replacement. Clin Orthop 1978;137:69. 46. Van Scoy RE, Wilkowske CJ: Prophylactic use of antimicrobial agents. Mayo Clin Proc 1983;58:241.
47. Carnady CR, Rodeheaver G, Thacker JG, et al: The crush injury: a high-risk wound. JACEP 1976;5:965.
48. BenVeniste K, Thut P: The effects of chronic alcoholism on wound healing. Proc Soc Exp Biol Med 1981;166:568. 49. Colin J, Elliot P, Ellis H: The effect of uraemia upon wound healing: an experimental study. Br J Surg 1979;60:793. 50. Hunt TK: Disorders of wound healing. World J Surg 1980;4:271.
51. Trott A: Mechanisms of surface soft-tissue trauma. Ann Emerg Med 1988;17:49.
Chapter 9.4 Ocular Foreign Bodies
Principles and Practice of Emergency Medicine