Acute Wounds (Professional Edition for Healthcare Providers)

Common mechanisms: Friction between skin and a rough surface (falls, sports, road rash from traffic accidents); high-speed friction can simultaneously cause friction burns and deep soft tissue injury.

Depth and tissue damage: Usually confined to the epidermis or superficial dermis; irregular surface, punctate bleeding, marked pain. Road rash may extend into the deep dermis with extensive embedded foreign material.

Contamination and infection risk: Gravel, asphalt, soil, glass, plant debris; incomplete cleansing can cause infection, traumatic tattooing, and delayed healing.

Potential deep structure injury: Generally uncommon; high-energy accidents still require exclusion of fractures, joint injuries, and deep soft tissue damage.

Essential workup: Visual inspection and palpation to confirm extent, depth, and foreign bodies; arrange imaging by site for high-energy trauma; assess tetanus vaccination history.

Initial management: Hemostasis, thorough irrigation, removal of gravel and foreign material; debridement under local anesthesia if needed; moist healing environment plus non-adherent dressing; monitor for increasing redness, swelling, pain, purulent exudate, and fever.

Closure method: Usually not sutured, healing primarily by secondary intention; large deep abrasions may require surgical debridement, skin substitutes, or skin grafting.

Referral criteria: Large or deep wounds; foreign bodies that cannot be completely removed; involvement of the face, hands, joints, or genitalia; suspected fracture, deep injury, or infection.

Common mechanisms: Cuts from knives, glass, metal fragments, or surgical instruments; the wound may appear small, but the depth may exceed what surface inspection suggests. (An incision refers to a sharp/surgical wound with clean edges; a cut may include non-surgical sharp injuries.)

Depth and tissue damage: Clean edges with minimal contusion; may extend from skin into subcutaneous tissue, fascia, muscle, or deeper layers.

Contamination and infection risk: Kitchen food, glass, metal, workplace contaminants; clean sharp objects carry lower risk, while contamination, delayed treatment, and immunocompromise increase risk.

Potential deep structure injury: Vessels, nerves, tendons, muscles, joint capsules, and bone; the palm, wrist, forearm, ankle, and neck especially require complete functional examination.

Essential workup: Exploration under adequate anesthesia, lighting, and hemostasis; document sensation, motor function, perfusion, and tendon function; arrange imaging when glass, metal, or bone injury is suspected.

Initial management: Direct pressure for hemostasis; cleansing, irrigation, removal of foreign bodies and devitalized tissue; assess tetanus prophylaxis and antibiotic indications.

Closure method: Clean wounds with viable tissue that can be adequately cleansed may undergo primary closure (sutures, staples, tissue adhesive, or closure strips); heavily contaminated, infected, or wounds of uncertain viability warrant delayed primary closure or secondary intention healing.

Referral criteria: Uncontrollable bleeding; suspected nerve, tendon, vessel, joint, or bone injury; extensive tissue loss or need for microsurgical reconstruction; injury to delicate structures of the face, eyelids, lips, or hands.

Common mechanisms: Blunt impact, falls, or tearing by irregular objects; often accompanied by tissue crushing, flap formation, or irregular edges.

Depth and tissue damage: Irregular edges with possible surrounding contusion, ischemia, or necrosis; surface length does not necessarily reflect the extent of deep injury.

Contamination and infection risk: Soil, clothing fibers, glass, wood splinters, metal, and saliva; crushed tissue, dead space, and devitalized flaps increase infection risk.

Potential deep structure injury: Nerves, vessels, tendons, muscles, joint capsules, and bone.

Essential workup: Complete neurovascular and tendon function examination; explore depth, undermining, dead space, and foreign bodies; X-ray, ultrasound, or CT as needed.

Initial management: Hemostasis, anesthesia, thorough irrigation; removal of foreign bodies and clearly devitalized tissue; preserve potentially viable important flaps, with specialist evaluation if necessary.

Closure method: Layered closure for clean, viable wounds; address deep dead space when present but avoid overly tight sutures; delay closure for heavily contaminated, severely contused, or high infection-risk wounds.

Referral criteria: Deep structure injury; extensive flap ischemia or soft tissue loss; wounds crossing joints, key facial structures, or functional zones of the hand; suspected retained foreign body or infection.

Common mechanisms: Penetration by nails, needles, wood splinters, fishhooks, sharp metal, etc.; plantar punctures, punctures near joints, and needlestick injuries deserve special attention.

Depth and tissue damage: Small surface opening but the wound tract may be very deep; the tract readily forms a hypoxic environment, and foreign material may be pushed deep into tissue.

Contamination and infection risk: Soil, rust, shoe sole material, wood fragments, and waterborne microorganisms; cellulitis, deep abscess, septic arthritis, or osteomyelitis may develop.

Potential deep structure injury: Tendons, nerves, vessels, joints, periosteum, and bone.

Essential workup: Identify the type, direction, and depth of the penetrating object and whether it was completely removed; X-ray to evaluate metal, glass, bone injury, or deep gas; ultrasound to help locate radiolucent foreign bodies; further imaging and specialist evaluation when joint or deep infection is suspected.

Initial management: Irrigation, removal of visible foreign bodies and clearly necrotic tissue; avoid blind deep probing of narrow wound tracts; assess tetanus prophylaxis, occupational exposure, and antibiotic indications.

Closure method: Most contaminated puncture wounds should not be tightly closed immediately; typically managed with open drainage, delayed closure, or secondary intention healing.

Referral criteria: Retained foreign body or inability to remove it safely; penetration into a joint, bone, thoracic or abdominal cavity, or near major neurovascular structures; deep plantar puncture with diabetes or sensory neuropathy; persistent worsening of pain, swelling, or infection.

Common mechanisms: Skin torn away by machinery, wheels, rings, or ropes; may form a local flap, circumferential degloving injury, or large-area avulsion.

Depth and tissue damage: Skin and subcutaneous tissue separate from the fascia; the flap may look acceptable while its microcirculation is already compromised; tissue loss, dead space, and delayed necrosis are common.

Contamination and infection risk: Road gravel, machine oil, clothing fibers, and soil; large amounts of devitalized tissue, hematoma, and dead space increase infection risk.

Potential deep structure injury: Fascia, muscle, tendons, nerves, vessels, and bone; circumferential degloving may compromise circulation of the entire limb segment.

Essential workup: Assess flap color, temperature, capillary refill, and bleeding response; complete neurovascular examination; skeletal and vascular imaging for high-energy trauma.

Initial management: Control bleeding and protect avulsed tissue with moist sterile dressings; avoid twisting or excessive traction on the flap; keep warm, provide fluids, and arrange early surgical debridement; completely amputated tissue should be properly preserved and transported with the patient.

Closure method: Depending on flap viability, options include in-situ replacement, layered closure, skin grafting, and local or free flaps; extensively contaminated wounds often require staged debridement and delayed reconstruction.

Referral criteria: Large-area avulsion, degloving, or tissue amputation; avulsion of the fingers, hand, scalp, face, or genitalia; suspected vascular injury or need for microsurgical reconstruction.

Common mechanisms: Bites from dogs, cats, humans, or other mammals; includes the clenched-fist injury (fight bite).

Depth and tissue damage: May present as puncture, laceration, crush, or tissue loss; cat bites have small external openings but often reach the tendon sheath or joint; dog bites more commonly cause crushing and tearing.

Contamination and infection risk: Mixed animal or human oral flora; human bites, hand bites, cat bites, and delayed presentation carry higher risk; also assess tetanus, rabies, and blood/body fluid exposure.

Potential deep structure injury: Tendons, tendon sheaths, joints, nerves, vessels, and bone.

Essential workup: Confirm animal species, health and vaccination status, and whether observation is possible; examine hand wounds through the wound tract in different joint positions; X-ray when fracture, retained tooth fragments, or joint involvement is suspected; consider deep specimen cultures when infected.

Initial management: Copious irrigation, debridement, removal of foreign bodies; assess prophylactic antibiotics; evaluate rabies PEP and tetanus prophylaxis according to exposure; treatment of infection should not be delayed to obtain cultures.

Closure method: Clean facial wounds may undergo selective primary closure after thorough management; hand wounds, deep punctures, heavily contaminated, or already infected wounds usually should not be tightly closed immediately — use delayed primary closure or secondary intention healing.

Referral criteria: Bites of the hand, face, periorbital area, genitalia, or near joints; deep invasion, rapidly progressing infection, or systemic symptoms; immunocompromise, asplenia, severe liver disease; unclear rabies exposure assessment or need for vaccine/immunoglobulin.

Common mechanisms: Compression by heavy objects, industrial machinery, traffic accidents, structural collapse, or prolonged limb compression.

Depth and tissue damage: The skin wound may be small, but deep muscle and vascular injury may be extensive; tissue necrosis may not appear until hours later; may be accompanied by rhabdomyolysis and systemic crush syndrome.

Contamination and infection risk: Soil, machine oil, building materials, metal, and clothing fragments; ischemic and devitalized muscle readily leads to deep infection.

Potential deep structure injury: Muscle, fascia, nerves, vessels, joints, and bone; compartment syndrome may develop.

Essential workup: Repeated neurovascular examinations; assess pain out of proportion to appearance, pain on passive stretch, and compartment pressures; X-ray or CT to evaluate fractures; in severe cases check CK, renal function, electrolytes, urinalysis, and ECG.

Initial management: Stabilize vital signs per trauma protocols; control bleeding, immobilize fractures, and protect the wound; in severe cases give fluids and monitor for hyperkalemia and kidney injury; emergency fasciotomy or extensive debridement when necessary.

Closure method: Tight closure should not be forced initially; repeated assessment and staged debridement are often required; options include delayed closure, negative pressure wound therapy (NPWT), skin grafting, or flap reconstruction.

Referral criteria: All moderate-to-severe crush injuries; neurovascular abnormalities, fractures, or suspected compartment syndrome; extensive necrosis, rhabdomyolysis, or systemic instability.

Common mechanisms: Friction, pressure, thermal injury, frostbite, contact dermatitis, or drug reactions; medical devices and adhesives can also cause blisters.

Depth and tissue damage: Fluid accumulation at the dermo-epidermal junction or within the epidermis; distinguish clear fluid, blood blisters, pus, and skin detachment.

Contamination and infection risk: Intact blisters are minimally contaminated; risk increases with rupture, repeated friction, or poor peripheral circulation.

Potential deep structure injury: Simple friction blisters usually do not injure deep structures; blood blisters may reflect stronger shear forces or deep tissue injury.

Essential workup: Identify the cause and extent of damage; in the diabetic foot, assess perfusion, sensation, and infection; multiple or widespread blisters require exclusion of autoimmune or severe drug-induced skin disease.

Initial management: Remove the source of friction or pressure; small intact blisters — preserve the epidermis and protect; large, painful, easily ruptured, or function-limiting blisters may be sterilely drained (whether to remove the blister roof depends on cause, location, and tissue viability); cleanse ruptured blisters and apply a non-adherent dressing.

Closure method: No sutures needed; management centers on protective coverage and re-epithelialization.

Referral criteria: Diabetic foot blisters, ischemia, infection, or deep pressure injury; large burn blisters; extensive mucosal lesions, fever, or suspected severe drug reaction.

Common mechanisms: Flame, hot liquids, steam, hot objects, chemicals, electrical current, friction, and radiation.

Depth and tissue damage: Superficial / superficial partial-thickness / deep partial-thickness / full-thickness; depth may progress over several days, and the initial assessment should not be regarded as final.

Contamination and infection risk: Fire-scene ash, clothing fragments, chemicals, and environmental microorganisms; large or deep burns carry increased risk of infection and sepsis due to loss of the skin barrier.

Potential deep structure injury: Subcutaneous fat, fascia, muscle, tendons, nerves, vessels, and bone; electrical injury can cause extensive destruction along deep tissues.

Essential workup: Depth and TBSA; airway and inhalation injury; in severe cases, blood gases, lactate, electrolytes, and renal function; consider CO and cyanide in enclosed-space fires; electrical injury requires ECG, CK, and monitoring.

Initial management: Stop the burning process and remove contaminated clothing and jewelry; cool with moderately cool running water (avoid ice packs and hypothermia); address ABCs before the wound; cover with clean dressings, keep warm, and provide analgesia.

Closure method: Superficial and superficial partial-thickness burns re-epithelialize naturally under dressings; deep partial-thickness or full-thickness burns may require eschar excision, skin grafting, or flap reconstruction.

Referral criteria: Determined by depth, TBSA, location, mechanism, age, comorbidities, and inhalation injury (see Section 9 of the Burn Section).

Common mechanisms: Planned or emergency surgical incision; may be clean, clean-contaminated, contaminated, or infected.

Depth and tissue damage: Depends on the surgical planes involved; may develop dead space, hematoma, seroma, or wound dehiscence.

Contamination and infection risk: The patient's own skin, respiratory, gastrointestinal, or genitourinary flora; emergency surgery, implants, prolonged operations, diabetes, obesity, and immunosuppression increase risk.

Potential deep structure injury: Depending on site, may involve fascia, muscle, body cavities, organs, vessels, or implants.

Essential workup: Incision integrity, redness, warmth, pain, exudate, hematoma, and dehiscence; imaging, laboratory studies, and deep cultures when deep infection is suspected; for abdominal wounds, watch for fascial dehiscence and evisceration.

Initial management: Confirm vital signs and severity of infection; evaluate for open drainage, debridement, or return to the operating room; control blood glucose, nutrition, pain, and systemic factors.

Closure method: Primary closure, delayed primary closure, or secondary intention healing; after dehiscence or infection, NPWT may be used with reconstruction as appropriate.

Referral criteria: Major bleeding, fascial dehiscence, or evisceration; deep/organ-space infection; implant infection or need for reoperation; persistent non-healing or recurrent dehiscence.

Common mechanisms: High-energy traffic accidents, falls from height, crush injuries, gunshot wounds, or a fracture end penetrating the skin from inside out.

Depth and tissue damage: The wound communicates with the fracture site (bone is not necessarily directly visible); often accompanied by periosteal stripping, soft tissue loss, and disrupted blood supply.

Contamination and infection risk: Soil, roadway, agricultural contamination, clothing fragments, and metal; high risk of deep infection, osteomyelitis, nonunion, and amputation.

Potential deep structure injury: Bone, periosteum, muscle, tendons, nerves, vessels, and joints.

Essential workup: Follow trauma protocols; complete neurovascular examination with repeated documentation; X-rays covering at least the injured bone and adjacent joints, with CT for complex injuries; arrange vascular imaging when vascular injury is suspected.

Initial management: Control bleeding, cover with sterile dressings, and immobilize the limb; administer systemic antibiotics early according to institutional guidelines; assess tetanus; arrange early joint evaluation by orthopedics/trauma/plastic surgery for debridement, fixation, and soft tissue coverage.

Closure method: Simple suturing in the emergency department before thorough debridement and fracture assessment is not appropriate; depending on contamination and viability, use primary coverage, delayed closure, NPWT, skin grafting, or flaps.

Referral criteria: All open fractures require urgent specialist evaluation; those with ischemia, severe contamination, segmental bone loss, or extensive soft tissue defects should be transferred to a hospital with full trauma and reconstructive capability.

A. High-pressure injection injury: High-pressure paint, hydraulic fluid, solvent, or water jet injected into the finger or palm. The external opening is tiny, but the material spreads extensively along fascia, tendon sheaths, and neurovascular bundles; mechanical pressure + chemical toxicity + ischemia + inflammation; delayed treatment can lead to necrosis, infection, loss of function, or amputation. Immediate neurovascular assessment and X-ray; elevate, provide analgesia, remove rings; avoid local compression, incision with squeezing, or digital ring block anesthesia; urgently contact hand surgery/plastic surgery — surgical exploration and debridement are usually required; use open or delayed closure. All high-pressure injection injuries are surgical emergencies requiring immediate referral.

B. Gunshot wounds: Penetrating, perforating, cavitation effects, and bone fragmentation; a small entry wound does not mean limited internal damage. Per ATLS, address ABCs and life-threatening hemorrhage first; do not blindly explore the bullet tract or retrieve bullets in the emergency department; arrange imaging by site; complete forensic evidence preservation and documentation. Closure depends on internal injury, contamination, and debridement findings; wounds of the trunk, neck, head, proximal limbs, or with neurovascular abnormalities require immediate transfer to a trauma center.

WHO includes thermal, electrical, friction, chemical, and radiation sources among burn causes; assessment tools should not cover only flame or hot water.

Use the Rule of Nines for adults; prefer the Lund–Browder chart for children; estimate scattered small areas using the patient's palm (including fingers) as approximately 1% TBSA. Fluid resuscitation calculations include only partial-thickness and full-thickness burns, not simple superficial erythema. (This site provides an interactive TBSA calculator with adult and pediatric age correction.)

Red flags: enclosed-space fire; burns of the face and neck; singed nasal hairs, soot around the nose and mouth, carbonaceous sputum; hoarseness, stridor, or respiratory distress; altered consciousness, headache, nausea. Normal oxygen saturation does not exclude carbon monoxide poisoning. When progressive airway edema is suspected, the airway should be managed early by an experienced team rather than waiting for severe obstruction before intubation.

Recommended: Stop the burning process; remove non-adherent clothing, diapers, rings, and watches; cool early with moderately cool running water; after cooling, cover with clean dressings and maintain core body temperature.

Contraindications / cautions: Do not apply ice or ice water directly; do not apply toothpaste, grease, unidentified ointments, or folk remedies; guard against hypothermia in large-area burns, infants, and the elderly; brush off chemical powders first, then irrigate according to the substance's properties; consult the SDS and poison information resources for special chemicals.

Calculation aids do not replace clinical judgment: first confirm whether resuscitation criteria are met; estimate the starting volume by body weight, TBSA, age, and the institutional formula; calculate from the time of injury (not the time of arrival); titrate to urine output, blood pressure, perfusion, and lactate; in children also consider maintenance fluids and glucose; adjust individually for electrical injury, inhalation injury, and delayed resuscitation; avoid formula-driven over-infusion causing fluid creep.

Circumferential full-thickness chest burns can restrict chest wall expansion; circumferential limb burns can impair distal perfusion. Continuously monitor pulses, Doppler signals, capillary refill, temperature, sensation, and pain; urgently evaluate for escharotomy when perfusion or ventilation compromise is suspected. Deep electrical injury or crush injury may additionally require fasciotomy — the indications for the two must not be conflated.

Select dressings according to depth, exudate, location, infection risk, and dressing-change pain; assess blister preservation, drainage, or removal; remove loose epidermis, contaminants, and clearly necrotic tissue; evaluate early excision and grafting for deep partial-thickness and full-thickness burns; for the hands, face, and joints, consider both functional and aesthetic reconstruction. Antimicrobial dressings are not equivalent to systemic antibiotics; systemic antibiotics should not be used routinely in the absence of clinical infection.

• Full-thickness burns
• Deep partial-thickness burns reaching a certain TBSA or potentially requiring surgery
• Deep burns of the face, hands, feet, genitalia, perineum, or major joints
• Suspected inhalation injury
• Chemical burns, high-voltage electrical injury, or lightning injury
• Circumferential chest or limb burns
• Associated major trauma or severe comorbidities
• Pediatric burns exceeding the capabilities of the initial facility
• Difficult pain control
• Suspected non-accidental injury or care safety concerns

Based on the latest American Burn Association burn referral criteria, localized according to the Taiwan burn care network and institutional referral criteria.

Healing time and hypertrophic scar risk; joint range of motion and early positioning; splinting, stretching, and occupational therapy; pressure garments and silicone products; itching, pain, and sensory abnormalities; sun protection; scar injections, laser, and surgical treatment; psychological support, body image, and return to work; long-term contracture follow-up during growth in children.