Treatment of Superficial Wounds in Road Traffic Accidents (RTAs)

Types of Superficial Wounds Seen in RTAs

Step-by-Step Management

1. Initial Assessment

• Assess ABCs (Airway, Breathing, Circulation) first - rule out life-threatening injuries before focusing on surface wounds
• Assess neurovascular status: check sensation and motor function before any local anaesthetic is given
• Obtain imaging if you suspect a foreign body (glass shards are common in RTAs), fracture, or dislocation underneath
• Document wound location, size, depth, contamination level, and time of injury

2. Analgesia / Anaesthesia

• Provide adequate analgesia before wound exploration and cleaning
• Local infiltrative anaesthesia (e.g. lignocaine/lidocaine) for lacerations requiring exploration or closure
• Topical anaesthetics (EMLA cream, LET gel) can be used for smaller wounds, especially in children

3. Wound Cleaning and Irrigation

• Irrigation with copious normal saline under pressure - particularly important for lower-limb wounds, which carry higher infection risk
• Remove all visible road grit, gravel, glass, and debris
• For abrasions: scrub gently with a soft brush and saline/antiseptic solution to remove embedded dirt (failure to remove embedded particles causes "traumatic tattooing")
• Antiseptics (povidone-iodine, chlorhexidine) may be used for initial cleaning of dirty wounds, but avoid leaving concentrated solutions in the wound as they can be cytotoxic to healing tissue
• Tap water is acceptable for wound cleansing and does not increase infection rates
• Tintinalli's Emergency Medicine, p. 1644

4. Haemostasis

• Apply direct pressure for 5-10 minutes for most superficial bleeding
• Elevation of the injured limb
• Wound closure itself usually provides haemostasis for lacerations

5. Wound Exploration and Debridement

• Explore all lacerations for foreign bodies, nerve/tendon injuries, and bone involvement
• Debride non-viable tissue until healthy bleeding is seen at wound edges
• Moist-to-dry dressings (saline-moistened gauze changed 2-3 times/day) can be used for dirty wounds requiring staged debridement
• Bailey & Love's Short Practice of Surgery, Table 3.2

6. Wound Closure

• Close skin without tension - use deep absorbable sutures (e.g. Vicryl) to reduce tension before skin closure
• Areas with high skin tension (knee, elbow) - use horizontal mattress sutures
• Deep lacerations involving fascia over muscle should have fascial repair with absorbable suture
• Small muscle lacerations do not require repair; large ones may need operative repair
• Tintinalli's Emergency Medicine, p. 1651-1653

7. Wound Dressing

• Cover sutured/stapled wounds with a protective, non-adherent dressing for 24-48 hours
• A moist wound environment accelerates re-epithelialization - occlusive/semi-occlusive dressings (e.g. Tegaderm, OpSite, Bioclusive) are preferred
• Remove dressing after 24 hours; cleanse wound gently with soap and tap water; inspect for infection signs
• Patients can wash wounds with tap water from 8 hours after closure without increased infection risk
• Tintinalli's Emergency Medicine, p. 2696-2698

8. Topical Antibiotics

• Topical antibiotics are generally not indicated for clean, non-infected wounds
• May be used selectively for:
  • Abrasions to prevent desiccation (mupirocin, fusidic acid)
  • MRSA-colonized wounds: mupirocin ointment
  • Burn-associated wounds: silver sulfadiazine or nanocrystalline silver dressings
• Mulholland & Greenfield's Surgery, p. 5995

9. Systemic Antibiotics

• Contaminated (class III) or dirty (class IV) wounds
• Grossly contaminated RTA wounds with soil/gravel
• Immunocompromised patients
• Impaired local circulation (peripheral arterial disease, lymphedema)

• Tintinalli's Emergency Medicine, Table 47-1

10. Tetanus Prophylaxis

• Give Tdap (tetanus + diphtheria + pertussis) for adults who have never received it or are >65 years old
• TIG dose: 250-500 IU IM (opposite deltoid from toxoid)

• Tintinalli's Emergency Medicine, Table 47-2; Bailey & Love's Surgery, Table 3.3

11. Follow-up and Monitoring

• Instruct patient on signs of infection: increasing redness, warmth, swelling, purulent discharge, fever
• Suture/staple removal timing:
  • Face: 3-5 days
  • Scalp: 7-10 days
  • Trunk/upper limb: 7-10 days
  • Lower limb: 10-14 days (slower healing)
• Scar management: sunscreen, silicone gel/sheets once healed
• Physiotherapy if near a joint or if range of motion is affected

Special Considerations in RTAs

• Traumatic tattooing: Embedded road grit in abrasions must be removed aggressively at initial treatment - once healed, it becomes permanent
• Glass foreign bodies: Not always visible on plain X-ray; ultrasound or CT may be needed
• Lower-limb wounds: Higher infection risk - more aggressive irrigation and consider antibiotic prophylaxis
• Degloving injuries: May appear superficial but involve loss of skin over a large area - requires specialist referral
• Time of repair: Clean wounds can be repaired up to 18-24 hours after injury; heavily contaminated wounds should have delayed primary closure

Vaginal Itching and Burning After Urination

Common Causes - Differential Diagnosis

The distinction between UTI symptoms and vaginitis is often difficult. Both Chlamydia and urine culture testing should be considered, particularly in young reproductive-age women. - Berek & Novak's Gynecology, p. 467

Diagnosis - Approach

History (Key Questions)

• Character of discharge: color, consistency, odor
• Sexual activity / new partner (STI risk)
• Recent antibiotic use (promotes candidiasis)
• Menopausal status (atrophic vaginitis)
• Diabetes, immunosuppression (recurrent/resistant candidiasis)
• Products used: soaps, douches, scented pads (contact dermatitis)
• Skin lesions (herpes, lichen sclerosus)

Examination

• Inspect vulva for erythema, edema, fissures, ulcers, white plaques
• Speculum exam: note discharge characteristics, cervical appearance
• "Strawberry cervix" (punctate hemorrhages) = trichomoniasis

Investigations

Treatment by Cause

1. Vulvovaginal Candidiasis (VVC)

• Oral: Fluconazole 150 mg single dose (most preferred by patients)
• Topical intravaginal azoles for 3-7 days (all equally effective):
  • Clotrimazole 2 x 100 mg vaginal tablets daily x 3 days
  • Miconazole 1200 mg vaginal suppository single dose
  • Butoconazole, terconazole, tioconazole - also available

• Prolonged or periodic oral azole therapy
• Vaginal culture to identify species and resistance (C. glabrata is often azole-resistant)
• Suppressive therapy: fluconazole 150 mg weekly x 6 months

• Oral azoles are contraindicated (adverse fetal outcomes)
• Use vaginal azoles x 7 days; ~80% cure rate

2. Bacterial Vaginosis (BV)

1. Grey-white homogeneous discharge
2. Vaginal pH >4.5
3. Positive whiff test (fishy odor with KOH)
4. Clue cells on wet mount (>20% of epithelial cells)

• Metronidazole 500 mg orally twice daily x 7 days (first-line)
• Clindamycin 300 mg orally twice daily x 7 days (alternative)
• Topical: Metronidazole 0.75% vaginal gel once daily x 5 days, or Clindamycin 2% vaginal cream x 7 days
• Treatment of male partners is NOT routinely recommended
• BV accounts for ~50% of all vaginal infections

3. Trichomoniasis

• Caused by Trichomonas vaginalis (sexually transmitted protozoan)
• 50% of patients are asymptomatic
• Symptoms: vaginal itching, malodorous yellow-green frothy discharge, vaginal irritation, external dysuria
• Diagnosis: motile flagellated protozoa on wet mount (50-65% sensitive); NAAT is more sensitive

• Metronidazole 2 g orally single dose (symptomatic patients)
• Alternative: Metronidazole 500 mg twice daily x 7 days
• In pregnancy: Metronidazole 500 mg BID x 7 days (intravaginal treatment not recommended in pregnancy)
• Treat sexual partners (STI - partner notification required)

4. Atrophic Vaginitis (Genitourinary Syndrome of Menopause)

• Caused by estrogen deficiency; common post-menopause
• Symptoms: vaginal dryness, burning, itching, dyspareunia, external dysuria, recurrent UTIs
• Exam: pale thin epithelium, loss of rugae, reduced secretions

• Topical vaginal estrogen (first-line): estradiol cream, estriol cream, or vaginal estradiol ring/tablet
• Non-hormonal: vaginal moisturizers (Replens), lubricants for intercourse
• Systemic HRT if other menopausal symptoms also present

5. Urethritis (STI-related dysuria)

• Caused by: N. gonorrhoeae, Chlamydia trachomatis, HSV
• Burning during urination + urethral discharge
• Test with NAAT on urine or urethral swab

• Chlamydia: Azithromycin 1 g orally single dose, or Doxycycline 100 mg twice daily x 7 days
• Gonorrhoea: Ceftriaxone 500 mg IM single dose (+ cover for chlamydia)
• If both suspected: treat empirically for both

6. Contact / Irritant Dermatitis

• Reaction to soap, feminine hygiene products, scented pads, latex, douches
• No infection present; pH and wet mount normal

• Identify and remove the offending agent
• Avoid douching, scented products, synthetic underwear
• Mild topical hydrocortisone 1% cream for inflammation
• Cool water rinse after urination to reduce burning

Red Flags - When to Refer / Investigate Further

• Symptoms not responding to standard treatment
• Recurrent episodes (>4/year) - rule out diabetes, immunosuppression, non-albicans Candida
• Visible ulcers or skin changes - rule out herpes, lichen sclerosus, VIN, malignancy
• Postmenopausal bleeding associated with vaginal symptoms
• Pelvic pain, fever - suspect PID (ascending infection)
• Pigmented vulvar lesions - warrant biopsy to exclude VIN or melanoma