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.
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Airway with C-spine control
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check that airway is patient
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If any signs of compromise they will need discussion and review by anaesthetics
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Breathing
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oxygen saturations, examine chest, examine work of breathing, breathing depth
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if concerns give high flow oxygen through a non-rebreathe mask
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Circulation
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pulse, blood pressure, capillary refill time, skin turgor, fluid input/output
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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)
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Give fluid challenge 250ml of crystalloid solution. If evidence of heavy bleeding apply pressure and activate Major Haemorrhage Protocol.
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Disability - GCS, pupils, blood sugar, temperature
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Exposure- systemic signs of shock, other injuries - this means a secondary survey.
Provide constant reassessment during this acute phase.
Focused history
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Allergies
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Medications – antiplatelets, anticoagulants
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Past medical history e.g. hypertension – may increase risk of heavy bleeding, smoking and alcohol
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Last meal
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Events leading up to this point
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Timing of injury
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Method of injury e.g. bottle – glass? single or multiple attacks
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Any self-defence – may have other injuries e.g. on hands
Examination and initial investigations
Examination
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Wound – size, depth of laceration – e.g. full thickness, location e.g. lip crosses vermillion border, will need specialist repair
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Cranial nerve examination e.g. cheek laceration – may have facial nerve injury
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Associated injuries e.g. lacerations to other part of body, head injury, orbital floor injury, dental trauma
Investigations
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X-ray area in case evidence of foreign body, associated fractures
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Bloods – FBC, U+E, CRP, Group and Save/cross match depending on severity of bleeding
Initial management
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Stop bleeding – apply pressure dressing
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Tetanus
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Antibiotics as per local microbiology guidelines
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Adequate fluid resuscitation
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Analgesia according to WHO ladder
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Keep nil by mouth
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Inform plastics/maxilla-facial surgeons/ENT registrar– if involving cosmetically sensitive area, concerns of associated injury eg fracture, nerve damage
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Prep for theatre – Anaesthetist – if unable to perform under local anaesthetic, Emergency theatres
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Keep patient and any relatives informed
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Document, document, document!!!
Escalation
Consider discussion with:
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Refer to plastics / ENT/ Maxillo-facial registrar – depending on area of laceration for specialist wound repair and closure and potential wound exploration
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Anaesthetics
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Theatres
