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Wound management

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 wounds.
  • 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 face5 days
Upper limb/trunk/abdomen7 days
Lower limb/diabetic/immunocompromised10 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)
    • Classify burn by determining depth: 

Classes of burns

ClassCharacteristicsManagement
SuperficialRed and dry, blanches with pressure (like sunburn)Simple moisturiser/Aloe vera gel
Partial-thickness (superficial/deep)Need re-epithelialisation ± granulation to healRed and moist, with blisters, does not blanchSee text below
Full-thicknessWhite/grey/scalded, insensate, solid, drySkin 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 
      • The Parkland formula estimates fluid requirements in 24 hours
        • Fluid requirement (ml) = 4 × total burn surface area (%) × body weight (kg)
        • 50% of this is given in the first 8 hours and 50% in the next 16 hours
        • Children should also be given maintenance fluids
    • 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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