Laceration to Cosmetically Sensitive Area

You are the CT1 covering plastic surgery and have been asked to review a patient in A+E who has sustained a laceration to their face following an assault with a glass bottle.

Example answer introduction

In this scenario I would be most worried about potentially significant haemorrhage and damage to underlying structures. I would assess this patient using an A-E approach, take a focused history and examination. I would arrange further investigations to confirm my diagnosis depending on my clinical suspicions and escalate the plastic surgical registrar.

Initial assessment + simultaneous resuscitation:

 

On arrival, manage the patient using an A to E approach according to the Advance Trauma Life Support Algorithm.

  • Airway with C-spine control

    • check that airway is patient 

    • If any signs of compromise they will need discussion and review by anaesthetics

  • Breathing

    • oxygen saturations, examine chest, examine work of breathing, breathing depth

    • if concerns give high flow oxygen through a non-rebreathe mask

  • Circulation

    • pulse, blood pressure, capillary refill time, skin turgor, fluid input/output

    • ensure IV access- 2 large bore etc- bloods as above, consider catheter (use clinical judgement as to if these are required if it is not a major trauma situation)

    • Give fluid challenge 250ml of crystalloid solution. If evidence of heavy bleeding apply pressure and activate Major Haemorrhage Protocol. 

  • Disability - GCS, pupils, blood sugar, temperature

  • Exposure-  systemic signs of shock, other injuries - this means a secondary survey. 

Provide constant reassessment during this acute phase.

Focused history​

  • Allergies

  • Medications – antiplatelets, anticoagulants

  • Past medical history e.g. hypertension – may increase risk of heavy bleeding, smoking and alcohol

  • Last meal

  • Events leading up to this point 

  • Timing of injury

  • Method of injury e.g. bottle – glass? single or multiple attacks

  • Any self-defence – may have other injuries e.g. on hands

Examination and initial investigations 

Examination

  • Wound – size, depth of laceration – e.g. full thickness, location e.g. lip crosses vermillion border, will need specialist repair

  • Cranial nerve examination e.g. cheek laceration – may have facial nerve injury

  • Associated injuries e.g. lacerations to other part of body, head injury, orbital floor injury, dental trauma

Investigations

  • X-ray area in case evidence of foreign body, associated fractures

  • Bloods – FBC, U+E, CRP, Group and Save/cross match depending on severity of bleeding

Initial management

  • Stop bleeding – apply pressure dressing

  • Tetanus

  • Antibiotics as per local microbiology guidelines

  • Adequate fluid resuscitation

  • Analgesia according to WHO ladder

  • Keep nil by mouth

  • Inform plastics/maxilla-facial surgeons/ENT registrar– if involving cosmetically sensitive area, concerns of associated injury eg fracture, nerve damage

  • Prep for theatre – Anaesthetist – if unable to perform under local anaesthetic, Emergency theatres 

  • Keep patient and any relatives informed

  • Document, document, document!!!

Escalation

Consider discussion with:

  • ​Refer to plastics / ENT/ Maxillo-facial registrar – depending on area of laceration for specialist wound repair and closure and potential wound exploration

  • Anaesthetics

  • Theatres

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