Clinical focus: Wounds and injuries range from superficial abrasions to life-threatening haemorrhage, airway injury, open fractures and penetrating trauma. Assess the patient before the wound, control bleeding before irrigation, preserve function and evidence, and use local surgical, tetanus and antibiotic protocols.
Learning objectives
- Define and classify wounds by mechanism, depth, contamination, timing and tissue involvement.
- Recognise life threats and perform a structured trauma assessment.
- Describe abrasions, contusions, lacerations, incised, puncture, bite, avulsion, crush, burn and firearm injuries.
- Apply haemorrhage control, irrigation, debridement, closure, analgesia, tetanus, antibiotic and referral principles.
- Recognise complications and medico-legal evidence requirements.
1. Definitions and classification
A wound is a disruption of tissue continuity caused by mechanical, thermal, chemical, electrical or biological energy. An injury is broader and includes internal damage without a skin break, such as a closed head injury or organ contusion.
| Classification | Categories | Why it matters |
|---|---|---|
| Skin integrity | Closed (bruise, haematoma, crush) or open (abrasion, laceration, cut, puncture) | Open wounds allow contamination and may need closure/tetanus assessment. |
| Mechanism | Blunt, sharp, penetrating, firearm, bite, thermal, chemical, electrical | Predicts hidden damage, contamination and specialist needs. |
| Depth | Superficial, partial-thickness, full-thickness, tendon/nerve/vessel/bone/cavity involvement | Determines functional assessment, imaging and operative referral. |
| Contamination | Clean, clean-contaminated, contaminated, dirty/infected | Guides irrigation, debridement, closure timing and antibiotic decisions. |
| Time | Acute, delayed, chronic or infected | Influences closure and infection risk; do not use an arbitrary “golden period” alone. |
| Forensic description | Antemortem, perimortem or post-mortem; self-inflicted, accidental or inflicted (only with adequate evidence) | Use neutral language; medical findings do not determine intent or guilt. |
2. First priority: find life threats
Use a structured trauma approach (ABCDE) and treat while assessing. A dramatic skin wound must never distract from airway obstruction, tension pneumothorax, internal haemorrhage, spinal injury or shock.
- A – Airway with cervical-spine protection: look for facial/neck wounds, swelling, blood, burns, hoarseness, stridor, dysphagia or expanding haematoma.
- B – Breathing: expose the chest; assess respiratory effort, oxygen saturation, breath sounds and penetrating chest wounds. Seal an open chest wound and treat tension physiology urgently.
- C – Circulation/haemorrhage: direct pressure, wound packing, tourniquet for life-threatening limb bleeding, two IV/IO lines, blood products and shock management.
- D – Disability: GCS, pupils, glucose, lateralising signs, spinal pain and limb neurovascular status.
- E – Exposure/environment: fully inspect for additional injuries, prevent hypothermia and preserve clothing/evidence.
3. Wound types and their forensic/clinical features
| Type | Definition and appearance | High-risk concerns |
|---|---|---|
| Abrasion/graze | Superficial epidermal loss from friction, scraping or pressure; may show direction or pattern. | Embedded gravel, infection, road rash, ocular involvement; clean thoroughly and document pattern. |
| Contusion/bruise | Blunt-force bleeding into tissue with intact skin; may be tender or swollen. | Internal injury, anticoagulants, bleeding disorder; colour cannot accurately date a bruise. |
| Haematoma | Local collection of blood; may be subcutaneous, intramuscular or internal. | Expanding neck/retroperitoneal haematoma, compartment syndrome or shock. |
| Laceration | Blunt tearing with irregular/abraded margins and tissue bridges. | Deep structure damage, foreign body and vascular bleeding. |
| Incised wound | Sharp-edge injury longer on the surface than in depth, usually clean margins. | Exsanguination, tendon/nerve/vessel injury and forensic comparison. |
| Stab/puncture | Pointed object penetrates; depth may exceed surface length. | Hidden chest/abdomen/vascular injury, retained foreign body and tetanus. |
| Avulsion/degloving | Skin/tissue partially or completely separated from underlying structures. | Ischaemia, contamination, tissue loss and need for reconstructive surgery. |
| Crush | Compression damages skin, muscle, vessels and nerves. | Compartment syndrome, rhabdomyolysis, hyperkalaemia, renal failure and crush shock. |
| Bite | Human or animal puncture, crush or avulsion with saliva/microbial inoculation. | Polymicrobial infection, tendon/joint involvement, rabies and tetanus. |
| Burn | Thermal, chemical, electrical or radiation tissue injury. | Airway injury, shock, circumferential compromise, ocular/chemical damage and sepsis. |
| Firearm/blast | Projectile or explosive energy causes entry/exit, cavitation, fragments and burns. | Internal bleeding, retained fragments, contamination and multiple casualties. |
4. Bleeding control
- Apply firm direct pressure with gauze or a clean dressing. Do not repeatedly lift the dressing to check; add layers if soaked.
- Pack deep junctional wounds (groin, axilla, neck where appropriate) with haemostatic gauze if trained; maintain pressure for the recommended time.
- Apply a commercial tourniquet above a life-threatening limb wound when direct pressure fails or the scene is unsafe. Note application time; do not loosen intermittently.
- For suspected pelvic or internal bleeding, minimise movement, keep warm, obtain large-bore IV/IO access, activate major haemorrhage protocol and arrange urgent surgery/interventional care.
- Assess distal pulses, capillary refill, sensation and motor function before and after compression or splinting.
5. Focused wound assessment
| Question | What to assess |
|---|---|
| When and how? | Time, mechanism, force, object, contamination, first aid, bite/saliva, chemical/electrical exposure and tetanus status. |
| Where and how deep? | Location, length/width/depth, tissue layers, cavities, exposed tendon/bone, foreign bodies and tissue viability. |
| What function is threatened? | Active/passive range of motion, tendon integrity, sensation, motor power, pulses, perfusion and compartment signs. |
| What systemic risks exist? | Shock, anticoagulants, diabetes, immunosuppression, renal disease, bleeding disorder, pregnancy and allergies. |
| What does imaging show? | Radiopaque foreign body, fracture, joint penetration, gas, chest/abdomen injury; ultrasound/CT according to site and stability. |
6. Cleaning, irrigation and debridement
Obtain haemostasis before irrigation. Use analgesia and local anaesthetic as needed. Irrigate with generous volumes of potable water or sterile saline using a syringe/appropriate pressure; remove visible debris and devitalised tissue while preserving viable structures. Do not blindly probe a deep puncture or force fluid/foreign material deeper. Suspected retained foreign body, tendon/nerve/vessel injury, joint penetration, eye injury or deep cavity wound requires specialist exploration.
- Clean the surrounding skin and move from least contaminated to most contaminated areas.
- Remove rings, bracelets and constricting items before swelling develops.
- Elevate and immobilise when appropriate; avoid hydrogen peroxide or strong antiseptics in deep tissue because they can injure viable cells.
- After irrigation, re-examine depth, function and haemostasis before deciding closure.
7. Closure and healing decisions
| Option | When considered | Limitations |
|---|---|---|
| Primary closure (suture, staple, adhesive, strip) | Clean, viable, adequately irrigated wounds with controlled contamination and low tension. | May trap bacteria in dirty, crushed, puncture or bite wounds. |
| Delayed primary closure | Contaminated wounds observed after cleaning/debridement when infection is not developing. | Requires review and a planned closure window. |
| Secondary intention | Infected, highly contaminated, tissue-loss or gaping wounds not suitable for immediate closure. | Slower healing, more granulation/scarring and need for dressings. |
| Specialist repair | Face, eyelid, lip vermilion, hand, tendon, nerve, vessel, genital, joint, exposed bone, deep bite or tissue avulsion. | Requires trained operator and may need theatre/microsurgery. |
Closure timing depends on site, vascularity, contamination, irrigation, patient factors and local protocol—not a rigid clock. Face wounds may be closed later than heavily contaminated lower-limb wounds; consult surgery when uncertain.
8. Analgesia and anaesthesia examples
| Medicine | Example adult use | Important cautions |
|---|---|---|
| Paracetamol/acetaminophen | 500–1000 mg orally every 6–8 hours; maximum commonly 4 g/day in a healthy adult | Use a lower maximum with liver disease, heavy alcohol use, malnutrition or low body weight; check combination products. |
| Ibuprofen | 200–400 mg orally every 6–8 hours with food; use the lowest effective dose | Avoid/seek advice in renal failure, dehydration, GI bleeding/ulcer, anticoagulation, NSAID allergy and later pregnancy; may worsen bleeding/renal perfusion. |
| Lidocaine 1% plain | Local infiltration; 1% = 10 mg/mL. Maximum commonly about 4.5 mg/kg (usually not exceeding 300 mg) without adrenaline | Aspirate before injection, avoid intravascular injection and reduce dose in frailty/liver disease. |
| Lidocaine with adrenaline | May prolong local effect and reduce bleeding in selected areas; maximum often about 7 mg/kg (local policy) | Use caution in end-arterial/poorly perfused areas and cardiovascular disease; follow local anaesthetic guidance. |
For severe pain, titrated opioid and regional anaesthesia may be needed in a monitored setting. Document dose, route, response and sedation/respiratory monitoring. Do not let analgesia replace evaluation for compartment syndrome or internal injury.
9. Tetanus prophylaxis
Assess wound contamination and documented vaccine history. Thorough cleaning and debridement are essential; antibiotics do not replace tetanus prevention.
| Situation | Typical approach (adult example) |
|---|---|
| Clean minor wound, complete primary series and recent booster | No booster if within the local recommended interval. |
| Dirty/major wound, complete series but booster not recent | Give tetanus-containing vaccine (commonly 0.5 mL IM) according to national interval. |
| Unknown/incomplete immunisation or dirty/major wound | Give vaccine and, when indicated, tetanus immunoglobulin (often 250 IU IM; use local product/protocol). |
| Immunodeficiency or HIV | Use national schedule and consider immunoglobulin for high-risk wounds even if history is uncertain. |
10. Antibiotics: when they help
Routine antibiotics are not needed for every simple, well-irrigated laceration. Consider prophylaxis or treatment for bites, gross contamination, devitalised tissue, open fractures, tendon/joint involvement, immunosuppression, diabetes, delayed presentation, deep puncture or infection.
| Scenario | Common adult example | Cautions |
|---|---|---|
| Human/animal bite prophylaxis or infection | Amoxicillin–clavulanate 625 mg orally three times daily or 875/125 mg twice daily for a short local-protocol course | Adjust for renal function, allergy and local resistance; severe infection may require IV therapy. |
| Severe penicillin allergy (bite) | Doxycycline 100 mg twice daily plus metronidazole 400–500 mg two/three times daily is used in some adult protocols | Avoid doxycycline in pregnancy/young children; check interactions and local guidance. |
| Open fracture/deep contaminated trauma | Immediate IV broad-spectrum prophylaxis (for example cefazolin-based protocol) with surgical irrigation/debridement | Do not delay surgery; add gram-negative/anaerobic cover according to grade and local guideline. |
Review at 24–48 hours when infection risk is high. Antibiotic adverse effects include allergy, diarrhoea, C. difficile and resistance; culture deep infection when possible.
11. Bites
- Human bites carry polymicrobial and blood-borne infection risk; clenched-fist injuries over knuckles may penetrate the joint/tendon sheath despite a small skin wound.
- Dog/cat bites require rabies risk assessment, wound irrigation, tetanus and selective antibiotics. Animal observation and vaccine/immunoglobulin decisions follow national rabies policy.
- Do not primarily close infected, puncture, hand or high-risk bite wounds without specialist advice; facial wounds may be selectively closed after excellent irrigation.
- Assess neurovascular/tendon function and foreign teeth; obtain imaging when a tooth, fracture or joint penetration is suspected.
12. Special injuries
Crush injury and compartment syndrome
Suspect with severe pain out of proportion, pain on passive stretch, tense swelling, paresthesia, weakness or worsening analgesic requirement. Check CK, potassium, creatinine, ECG and urine; begin careful fluid resuscitation according to trauma/renal protocol and involve surgery urgently. Pulses may remain present until late.
Open fracture
Cover with sterile dressing, document neurovascular status, immobilise, give analgesia, administer IV antibiotics and tetanus promptly, and arrange urgent orthopaedic irrigation/debridement. Do not repeatedly inspect or probe the wound in the emergency area.
Eye, face, neck and hand wounds
These are functionally critical. Protect a suspected open globe with a rigid shield (not pressure), avoid topical manipulation, and obtain urgent ophthalmology. Repair of eyelid margin, lip vermilion, tendon, nerve, vessel or complex hand wounds should be specialist-led.
Penetrating chest/abdomen
Do not remove an impaled object outside theatre unless required for airway/CPR. Seal an open chest wound, assess for tension physiology, activate trauma pathways and use imaging/surgery based on stability.
13. Infection and other complications
| Complication | Clues | Action |
|---|---|---|
| Cellulitis/wound infection | Increasing pain, warmth, erythema, swelling, pus, fever or lymphangitis | Reassess depth/foreign body, culture when indicated, antibiotics and drainage. |
| Necrotising soft-tissue infection | Severe pain, rapid progression, toxicity, bullae, crepitus or skin anaesthesia | Immediate broad-spectrum IV antibiotics, resuscitation and surgery—do not wait for imaging. |
| Dehiscence | Closure separation, drainage or gaping | Assess infection and tissue viability; urgent review for deep or facial wounds. |
| Compartment syndrome | Pain out of proportion, passive stretch pain, tense compartment, sensory/motor change | Emergency orthopaedic assessment and fasciotomy when diagnosed. |
| Functional deficit | Loss of movement, sensation or pulse | Repeat neurovascular exam, splint and urgent specialist repair. |
| Abnormal scar/keloid | Raised, itchy or painful scar | Wound review and dermatology/plastic-surgery management. |
14. Forensic and medico-legal essentials
- Photograph injuries with consent, an identifier, date/time and scale; keep originals secure.
- Describe dimensions, location, direction, shape, colour, edge, tissue bridges, foreign material and function; do not infer a weapon or intent from appearance alone.
- Collect clothing, swabs or debris only after consent and according to evidence-kit protocol; label, seal and document every transfer.
- Record the patient’s account in quotation marks where useful and distinguish history from examination and opinion.
- Document the presence and absence of injuries. A normal examination does not exclude violence.
15. Discharge and follow-up
Explain wound care, dressing changes, bathing, activity, suture/staple review, antibiotics, analgesic limits, tetanus, danger signs and a safe contact method. Return urgently for fever, spreading redness, pus, worsening pain, bleeding, numbness, colour change, loss of function, shortness of breath, confusion, severe swelling or uncontrolled pain. Arrange review based on site and complexity—often 24–48 hours for high-risk wounds and 5–14 days for closure removal depending on site.
16. Worked cases
Case 1: Deep forearm laceration
After ABCDE, direct pressure controls bleeding. The patient cannot extend a finger and has reduced sensation. Do not simply close the skin. Document motor/sensory/pulses, cover, splint, give analgesia/tetanus, obtain imaging if needed and refer urgently for tendon/nerve repair.
Case 2: Clenched-fist human bite
A tiny wound over the knuckle may communicate with the joint. Irrigate, image, give bite-appropriate antibiotic prophylaxis and tetanus, avoid primary closure and obtain urgent hand-surgery review.
Case 3: Crush injury
A patient trapped for hours develops severe limb pain, dark urine and potassium 6.2 mmol/L. Treat as crush syndrome: ECG/monitoring, hyperkalaemia emergency pathway, cautious fluid/renal management, CK/creatinine testing and urgent surgical assessment for compartment syndrome.
17. Quick self-test
- What comes before wound irrigation in an actively bleeding wound?
- Name three findings that suggest compartment syndrome.
- Why are puncture wounds not blindly probed?
- When are antibiotics more strongly indicated?
- Does wound colour reliably date a bruise?
Answers
- Haemorrhage control and assessment for life-threatening injury.
- Pain out of proportion, pain on passive stretch, tense swelling, paresthesia or weakness.
- Blind probing can push foreign material deeper and injure structures; explore under direct vision or refer.
- Bites, gross contamination, devitalised tissue, open fractures, deep punctures, tendon/joint injury, delayed presentation or high-risk patients.
- No. Bruise colour is affected by skin tone, depth, disease and healing and cannot accurately date an injury.
Key take-home points
- Assess the whole trauma patient first; control life-threatening bleeding before wound care.
- Describe wound type, mechanism, depth, contamination, function and neurovascular status systematically.
- Haemostasis precedes irrigation; remove foreign bodies under vision and preserve viable tissue.
- Use selective closure, tetanus and antibiotic decisions based on contamination, mechanism, anatomy and host risk—not a rigid clock.
- Hand, face, eye, neck, genital, joint, tendon, nerve, vessel, open-fracture and penetrating wounds need early specialist input.
- Objective documentation and chain of custody protect both patient care and justice.
References and further reading
- WHO: Improving care of the injured
- NCBI Bookshelf: Wound classification
- MSD Manual Professional: Skin lacerations
- MSD Manual Professional: Cleanse, irrigate, debride and dress wounds
- MSD Manual Professional: Human and mammal bites
- MSD Manual Professional: Tetanus and wound care
Educational note: Medication doses are adult examples and require checking local guidelines, allergies, pregnancy, renal/liver function, weight and interactions. Emergency clinicians should escalate early when depth or function is uncertain.
