A 9-year-old boy is brought in for evaluation of facial abrasions after falling down in the schoolyard. He unfortunately fell face first on pavement with loose gravel causing this painful abrasion around his left eye. The center of the wound is darkened with dirt and debris from the asphalt still embedded deeply in the wound. He is frightened about what you are planning to do, and mom is terrified that this will leave a bad scar.
How would you as a health care provider manage this wound?
One of the more painful (for the patient) and frustrating (for medical providers) situations in emergency medicine and urgent care practice is the management of significant epidermal abrasions–more commonly referred to as “road rash.” I was interviewed for my take on this problem by the folks at EMRAP. It’s part of the opening segment of the November 2017 episode. It’s a really interesting discussion among several physicians, and if you are subscriber I’d encourage you to take a listen. I’ll use this forum to further elaborate on my contribution to the segment.
Below in Part I we’ll discuss cleansing of the wound. In Part II (to follow shortly) we’ll discuss how to optimally dress the wound. If you are a patient and accidentally stumbled on this page, you may want to look here instead: this is an easy-to-follow guide on management of your abrasions after the emergency department or urgent care clinic.
Take a step back
First thing to note: road rash should be viewed in light of the larger picture. Recognizing that the majority of these patients experienced a significant traumatic injury causing their abrasions–often, they wiped out on a motorcycle or bike–road rash should first and foremost be thought of as a marker for more serious internal injury. This is the typical ATLS “ABC” trauma approach, and rings true here.
Secondly, it’s wise to recognize the great misnomer of the colloquial term: this rash is actually a burn (generally from friction, but also sometimes thermal), and thus we should evaluate it and treat it as such. This means starting with assessment of depth and TBSA (which is these days best accomplished with the help of a smartphone app). Then, use this data to determine whether the patient requires fluid resuscitation, burn center transfer, and consultation with (or referral to) a burn surgeon for wound management. The worst of these injuries may even be candidates for skin grafting.
On to the wound…
With all this said, most of the road rash we see is minor, and it is more a matter of observing best wound care practices to optimize cosmetic outcome.
So what’s the best way to do it? If you listen to the EMRAP segment, you’ll recognize that there is no single “right” way, and over time all practitioners develop a nuanced, personalized management. But if you are interested, here’s how I do it.
The first step is to get that wound clean.
As a first step, I generally have the patient run the wound under tap water to see how much of the superficial material will simply slough off painlessly. Generally, I run the water on the cooler side. If you return to my paradigm and think about road rash as a burn, where cooling is a recommended first aid measure in the initial presentation, this makes total sense. Potential benefits of cooling include pain relief, reduced depth of injury, and even reduced need for grafting. It is most effective if performed immediately, but may be of benefit even 1-3 hours after an injury. What I can’t tell you specifically in the setting of road rash is the optimal duration of irrigation or temperature, as these aren’t well studied. Rather, titrate it to patient comfort level with a goal of removing as much foreign matter as possible.
If the patient is having a tough time tolerating even this step, you may want to consider modalities of analgesia. The best choice will depend on anatomic location. If the area is amenable to a regional block like a facial nerve block or a block of the extremity, go for it. If not, IV and/or topical analgesics like 4% lidocaine/epinephrine/tetracaine (LET) can also be useful tools. Be mindful with very large surface area abrasions, one might approach the toxic dose of lidocaine (commonly quoted at 6.4 mg/kg) if applied indiscriminately.
Now, stop and assess the wound. Is it clean-based, pink, and free of debris? If so, you may be done with the cleansing step. On the other hand, if there is foreign matter still embedded in the wound, you’ll need to progress to the next step.
To really clean road rash of all foreign matter and debris, you may need to scrub and debride that wound. Use whatever you have available, and whatever it takes. Typically I will use an OR scrub brush–that’s largely because it is what is most readily available. Another useful tool for “detail work” is a firm-bristled toothbrush.
The key point to remember here is that this is probably the most painful step for the patient. Don’t be shy about liberal use of IV analgesics in these patients. In children I have even employed procedural sedation in selected cases.
Why so aggressive here? The reason you need to scrub, scrub, scrub is to prevent the phenomenon of “traumatic tattooing” of the wound. Despite the discomfort and extra effort, plenty of literature exists citing the initial presentation as the optimal moment to get the dirt out–it is much harder to do once re-epithelialization begins.
Stay tuned for Part II, to follow Thursday, in which we’ll discuss optimal dressings for road rash injuries.