Minor bruises and wounds

Bruises

A bruise is a collection of blood that develops in soft tissue (muscle, skin, or fat), caused by a direct blow to the body part, a tearing motion (such as a twisted ankle), or spontaneous bleeding (ruptured or leaking blood vessel). With trauma, tiny blood vessels are torn or crushed and leak blood into the tissue, so that it rapidly becomes discolored. Pain and swelling are proportional to the amount of injury. People on anticoagulants (such as warfarin or a direct oral anticoagulant, such as apixaban) and hemophiliacs tend to develop larger bruises; elders and those taking steroid medications tend to bruise easily, often spontaneously.

The immediate (within the first 48 hours) treatment of a bruise is to apply cold compresses or to immerse the injured part in cold water (such as a mountain stream). This decreases the leakage of blood, minimizes swelling, and helps reduce pain. Cold applications should be made for intermittent 10-minute periods until a minimum total application time of 1 hour is attained. To avoid frostbite, don’t apply ice directly to the skin. Wrap the ice in a cloth before application.

If the swelling progresses rapidly (such as with bleeding into the thigh), an elastic bandage can be wrapped snugly to try to limit the swelling. Continue cold applications over the wrap. It’s important to keep the wrap loose enough to allow free circulation. Fingertips and toes should remain pink and warm; wrist and foot pulses should remain brisk. Elastic wraps can be helpful if pain and swelling will not allow the victim to extricate themself to seek medical attention.

Elevation of the bruised and swollen part above the level of the heart is essential, to allow gravity to further keep swelling to a minimum.

Never attempt to puncture or cut into a bruise to drain it. This is fraught with the risk of uncontrolled bleeding and the introduction of bacteria that cause infection. The exception to this rule is a tense and painful collection of blood under the fingernail (see below).

After 48 to 72 hours, application of moist or dry heat will promote local circulation and resolution of swelling and discoloration. Heat ointments, balms, and liniments don’t transfer real heat. They are chemical or botanical substances that make the skin feel warm by stimulating nerve endings in the outermost layers of the skin and sometimes causing small blood vessels to dilate. This does not hasten healing but might help a bit with soreness and stiffness. These substances should only be used on intact skin and never on mucous membranes.

People who have prolonged blood-clotting times and/or who have large bruises should avoid products that contain aspirin, which might cause increased bleeding. A hemophiliac who sustains an expanding bruise will likely need to be transfused with a blood-clotting “factor” to promote coagulation; transport to a medical facility should be prompt.

A severe bruise, usually caused by a direct blunt force, can on rare occasion develop into a compartment syndrome (see page 85).

Black eye

A black eye is a darkened blue or purple discoloration in the region around the eye. It can be caused by a direct blow (bruise) or by blood that has settled into the area from a broken nose, skull fracture, or laceration of the eyebrow or forehead. “Raccoon eyes” are black eyes caused by a skull fracture. If a black eye is due to a direct injury (with swelling and pain), first examine the eyeball for injury (see page 204). The skin discoloration can be treated with intermittent cold compresses for 24 hours.

Blood under the fingernail

When a fingertip is smashed between two objects, there is frequently a rapid blue discoloration of the fingernail, which is caused by a collection of blood underneath the nail. Pain from the pressure can be quite severe. To relieve the pain, it’s necessary to create a small hole in the nail directly over the collection of blood, to allow the blood to drain and thus relieve the pressure. This can be done during the first 24 to 48 hours following the injury by drilling a small hole in the nail by twirling a scalpel blade, sharp knife, or needle. As soon as the nail is penetrated, blood will spurt out, and the pain will be considerably lessened. Another technique is to heat a paper clip or similar-diameter metal wire to red-hot temperature in a flame (taking care not to burn your fingers while holding the other end of the wire; use needle-nose pliers, if available). Quickly and steadily press the glowing-hot wire through the nail until it is penetrated ( Fig. 178 ). Before and after the procedure, the finger should be washed carefully. If the procedure was not performed under sterile conditions, administer dicloxacillin, erythromycin, or cephalexin for 3 days.

Torn fingernail

If a fingernail is torn in such a manner that it is partially removed from the nail bed, carefully clean the wound and decide whether you can leave the nail in place as is or whether you need to trim it in order to make it easier to apply a clean dressing. If you decide to trim the nail, take care to not cut away any of the nail root (lowest portion of the nail that tucks under the skin). If the nail has been torn off, then cover the nail bed with something nonadherent, such as a piece of Vaseline gauze, or bacitracin underneath a nonstick piece of Telfa. If you use a dressing that sticks to the nail bed, it will become encrusted and be difficult and painful to remove without soaking.

Puncture wounds

Puncture wounds are most frequently caused by nails, tree branches, thorns, fishhooks, and the like. Because they don’t drain freely, these wounds carry a high risk for retained bacteria and subsequent infections. A puncture wound should be irrigated copiously with the cleanest solution that’s available and left open to heal. Bleeding washes bacteria from the wound, so a small amount of bleeding should be encouraged. Never suture or tape a puncture wound closed, unless necessary to halt profuse bleeding; doing so promotes the development of infection. Similarly, don’t occlude the opening of a puncture wound with a “grease seal” or plug of medicinal ointment; apply any antiseptic sparingly. If the wound is more than ¼ inch (0.6 cm) at its opening, you can leave a piece of sterile gauze in the wound as a wick for a day or two, to allow drainage and prevent formation of an abscess cavity (see page 262). If the wound becomes infected (see page 295), apply warm soaks four or more times a day. Treat the victim with dicloxacillin, erythromycin, or cephalexin for 4 days.

Impaled object

See page 68.

Scrapes

Scrapes (abrasions) are injuries that occur to the top layers of skin when it is abraded by a rough surface. They are generally very painful because large surface areas with numerous nerve endings are involved. Bleeding is of an oozing, rather than free-flowing, nature.

An abrasion should be scrubbed until every speck of dirt is removed. Although it hurts just to think about this, scrubbing is necessary for two reasons. The first is the infection potential when such a large area of injured skin is exposed to dirt and debris. The second is that if small stones or pieces of dirt are left in the wound, these in essence become like ink in a tattoo, leaving the victim with permanent markings that sometimes require surgical excision. Soap-and-water scrubbing with a good final rinse should be followed with an antiseptic ointment such as bacitracin or mupirocin, or cream such as mupirocin, and a sterile nonadherent dressing or Spenco 2nd Skin. You can also place Hydrogel occlusive dressing over an abrasion; it will absorb up to 2 ½ times its weight in fluid weeping from the wound. It should be covered with a dry, light dressing. This technique is useful for burns as well. If the surface area is not particularly large or is on a difficult-to-bandage area, such as the nose or ears, the bandage (not the ointment) can be omitted.

The pain of cleansing can be relieved by applying pads soaked with lidocaine 2.5% ointment to the abrasion for 10 to 15 minutes before scrubbing. To avoid lidocaine toxicity, don’t do this if the surface area of the abrasion exceeds 5% of the total body surface area (an area approximately five times the size of the victim’s fingers and palm). In some cases, particularly when there is deeply embedded grime that will be extremely painful to remove, it’s useful to inject the wound with a local anesthetic (see page 282).