10.18 Traumatic Tattoos and Abrasions
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agk's Library of Common Simple Emergencies

Presentation
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The patient will usually have fallen onto a 
coarse surface such as a blacktop or macadam 
road. Most frequently, the skin of the face, 
forehead, chin, hands and knees are abraded. 
When pigmented foreign particles are 
impregnated within the dermis adventita, 
tattooing will occur. An explosive form of 
tattooing can also be seen with the use of 
firecrackers, firearms, and homemade bombs.

What to do:
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- Cleanse the wound with nondestructive agents 
    (e.g., normal saline, SurClens, 1% 
    povidone-iodine in normal saline) and 
    provide tetanus prophylaxis.
- With explosive tattooing, particles are 
    generally deeply embedded and will require 
    plastic surgical consultation. Any 
    particles embedded in the dermis may become 
    permanent tattoos. Abrasions that are both 
    large (more than several square centi- 
    meters) and uniformly deep into the dermis 
    or below (so that no skin appendages, such 
    as hair follicles, to provide a reservoir 
    of regenerating basal epithelium remain), 
    may also require consultation and/or skin 
    grafts.
- With abrasions and abrasive tattooing, the 
    area can usually be adequately anesthetised 
    by applying lidocaine jelly, viscous 
    lidocaine or gauze soaked with a mixture of 
    lidocaine, tetracaine and epinephrine 
    directly onto the wound for approximately 5 
    minutes. If this is not successful, locally 
    infiltrate with 1% buffered lidocaine using 
    a 25-gauge 3" needle for large areas.
- The wound should now be cleaned with a 
    surgical scrub brush, saline and surgical 
    soap. When impregnated material remains, 
    use a sterile stiff toothbrush to clean the 
    wound or use the side of a #10 scalpel 
    blade to scrape away any debris. While 
    working, continuously cleanse the wound 
    surface with gauze soaked in normal saline 
    to reveal any additional foreign particles. 
    Large granules may be removed with the tip 
    of a #11 blade.
- Wounds should be left open with antibiotic 
    ointment applied. The patient should be 
    instructed to gently wash the area 3-4 
    times per day and continue applying the 
    ointment until the wound becomes dry and 
    comfortable under a new coat of epithelium, 
    which may require a few weeks.
- An alternative to the above when the wound 
    has been adequately cleansed, is to use the 
    same antibiotic ointment with a closed 
    dressing of Adaptic gauze and a scheduled 
    dressing change within 2-3 days.
- Provide wound care instructions that include 
    danger signs of infection.

What not to do:
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- Do not ignore embedded particles. If they 
    cannot be completely removed, inform the 
    patient about the probability of permanent 
    tattooing and arrange a plastic surgical 
    consultation.

Discussion:
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The technique of tattooing involves painting 
pigment on the skin, and then injecting it 
through the epidermis into the dermis with a 
needle. As the epidermis heals, the pigment 
particles are ingested by macrophages and 
permanently bound into the dermis. Immediate 
care of traumatic tattoos is important because 
once the particles are embedded and healing is 
complete, it becomes difficult to remove them 
without scarring. It is advisable for a patient 
to protect a dermabraded area from sunlight for 
approximately 1 year to minimize excessive 
melanin pigmentation of the site.

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
 Longwood Information LLC 4822 Quebec St NW Wash DC
 1.202.237.0971 fax 1.202.244.8393 electra@clark.net
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