Wound management

Acutely Unwell Patients > Managing trauma

Initial approach

Use an advanced trauma life support/ABCDE approach in life-threatening wounds
Severe haemorrhage may require pressure, elevation and use of a tourniquet or arterial clamp/suture

Clean and debride wound

Clean wound and area using multiple sterile gauze soaked in sterile saline
Anaesthetise: infiltrate 1% lidocaine subcutaneously around wound edges
Mechanical cleansing (debridement): remove any debris/contamination/foreign bodies/dead tissue. Use sterile gauze soaked in saline to scrub; and forceps and a scalpel to excise tissue if required.
Pressure irrigation (can omit if wound is clean): squirt sterile saline into the wound using pressure (from syringe via green needle or from pressure infusion bag via orange cannula)
Deep inspection: thoroughly re-inspect the whole of the wound (may need wound edge retraction), look at deep structures as able, and ask the patient attempt full range of movement to help look for tendon damage
Perform any further cleansing/irrigation if required – some wounds require more thorough debridement:
- Wound debridement under general anaesthesia is required if large, extensive debris, lots of necrotic skin, dead muscle, contamination, underlying fracture or neurovascular compromise
- Urgent surgical exploration is required if there is any possibility of nerve/vessel/tendon/organ damage

Closure options

Immediate primary closure

Immediate closure with sutures/clips/Steri-Strips/glue
This is only used if there is negligible skin loss, the wound is clean with no foreign bodies, <12 hours old (<24 hours for face wounds), and the edges come together easily without tension

Delayed primary closure

Wound cleaned thoroughly, then dressed and left open for 48 hours
The wound is then reviewed for signs of infection, swelling and bleeding
If these are absent and the wound edges can be opposed without tension, the wound is sutured closed
This is used for contaminated wounds, contused/bruised wounds, infected wounds, or wounds >12 hours old
Antimicrobial dressings and prophylactic antibiotics should also be used for contaminated/infected wound

Secondary intention

Allow wound to close by itself, i.e. by granulation, epithelialisation and scarring
This is used for wounds with tissue loss preventing edge approximation, chronic ulcers and partial-thickness burns

Skin grafts

For significant skin loss (including most full-thickness burns)

Other aspects to management

Infected or contaminated wounds require antibiotics
Consider tetanus booster/immunoglobulin if patient is not up to date with tetanus vaccines (5 total) or high-risk wound
Consider rabies immunoglobulin if high risk wound in high risk area
Analgesia, e.g. Entonox, morphine IV, regional anaesthesia
If swelling likely – rest, ice, elevation for 24 hours
Select appropriate dressing (a primary dressing is placed directly on wound and a secondary dressing is placed over this to provide further protection)
Consider correcting any factors which may hinder wound healing, e.g. stop smoking/NSAIDs, give nutritional supplements

Follow up

Give patient wound advice
Injured limbs need elevation for 24-48 hours
Arrange follow-up for: wounds for delayed primary closure (to close), diabetic or immunocompromised patients (to review healing), burns (to look for infection)
Suture removal:

Head and face	5 days
Upper limb/trunk/abdomen	7 days
Lower limb/diabetic/immunocompromised	10 days

Wounds requiring special management

Burns

Initial assessment

Test sensation, blanching and check tetanus status
Determine the % body surface area involved using rule of 9’s (head 9%, arm 9%, leg 18%, trunk front 18%, trunk back 18%), palmar surface (patient’s palm and fingers = 0.8%) or a Lund and Browder chart (more accurate, especially in children)

Classes of burns

Class	Characteristics	Management
Superficial	Red and dry, blanches with pressure (like sunburn)	Simple moisturiser/Aloe vera gel
Partial-thickness (superficial/ deep) Need re-epithelialisation ± granulation to heal	Red and moist, with blisters, does not blanch	See text below
Full-thickness	White/grey/scalded, insensate, solid, dry	Skin graft

Initial management for all major burns should begin with an ABCDE approach

Airway burns: call anaesthetist and intubate patient as soon as possible
Breathing: give all patients 100% oxygen through a humidified non-rebreather mask; nebulisers for smoke inhalation
Circulation: site 2 large bore cannulas and commence IV fluid resuscitation
Disability: check responsiveness, give strong analgesia
Exposure: examine entire skin and look for other injuries
- Large area burns: cover with sterile sheets or cling film until specialist review
- Minor burns: immerse in cool water for 30 minutes (or cover with cool sterile saline soaked towels)

Further management of partial-thickness burns

Use systemic (never topical) analgesia if required
Cleanse with soap and water, then thoroughly rinse
Scrub off any necrotic tissue
Dress simple low-exudate burns with multiple layers of low-adherent impregnated tulle gauze. Cover this with a sterile non-adherent absorbent pad dressing and secure with bandages or dressing fixing tape.
Review in 48 hours to look for signs of infection
Re-dress every 2 days

Blisters

Leave intact unless they are open/contaminated (fully debride) or are large/prevent dressing (sterile aspiration)

Burns requiring specialist opinion/admission

Full thickness burns (need skin graft)
>10-15% body surface area or if elderly/significant comorbidities (risk of significant fluid loss)
Hands (put in bag with paraffin and keep moving)
Face (use Vaseline); genitalia/perineum (admit as difficult to dress)
Burns over major joints; chemical (‘irrigate, irrigate, irrigate!’)
Electrical (spare skin); inhalation injuries (airway risk)
Circumferential burns (risk of compartment syndrome)

Puncture wounds

X-ray if any possibility foreign body
If wound is deep and contaminated, it needs wide debridement in theatre
If not, use simple debridement and irrigation
Follow-up is required

Bites

Cat and human bites are worst
High risk of tendon injury and joint contamination leading to risk of septic arthritis
Most require aggressive surgical management, often followed by delayed primary closure/healing by secondary intention
Give antibiotics for 5 days

Others

Gunshot wounds are usually treated with thorough debridement and delayed primary suture
Facial injuries should ideally be sutured by a plastic surgeon– use fine sutures and remove after 2-5 days
Crushed tissues need to be elevated for 7-10 days to reduce swelling prior to closure (risk of compartment syndrome)

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What is the Parkland formula?

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Wound management

Initial approach

Clean and debride wound

Closure options

Other aspects to management

Follow up

Wounds requiring special management

Here’s some questions

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Managing trauma