Table of Contents Initial approach Clean and debride woundClosure options Immediate primary closureDelayed primary closureSecondary intentionSkin graftsOther aspects to management Follow upWounds requiring special management BurnsPuncture woundsBitesOthersHere’s some questions Initial approach Use an advanced trauma life support/ABCDE approach in life-threatening woundsSevere 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 compromiseUrgent 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/glueThis 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 hoursThe wound is then reviewed for signs of infection, swelling and bleedingIf these are absent and the wound edges can be opposed without tension, the wound is sutured closedThis is used for contaminated wounds, contused/bruised wounds, infected wounds, or wounds >12 hours oldAntimicrobial 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 scarringThis 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 antibioticsConsider 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 areaAnalgesia, e.g. Entonox, morphine IV, regional anaesthesiaIf swelling likely – rest, ice, elevation for 24 hoursSelect 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 adviceInjured limbs need elevation for 24-48 hoursArrange 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 daysUpper limb/trunk/abdomen7 daysLower limb/diabetic/immunocompromised10 days Wounds requiring special management Burns Initial assessment Test sensation, blanching and check tetanus statusDetermine 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 ClassCharacteristicsManagementSuperficialRed and dry, blanches with pressure (like sunburn)Simple moisturiser/Aloe vera gelPartial-thickness (superficial/deep)Need re-epithelialisation ± granulation to healRed and moist, with blisters, does not blanchSee text belowFull-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 inhalationCirculation: site 2 large bore cannulas and commence IV fluid resuscitation Disability: check responsiveness, give strong analgesiaExposure: examine entire skin and look for other injuriesLarge area burns: cover with sterile sheets or cling film until specialist reviewMinor 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 requiredCleanse with soap and water, then thoroughly rinseScrub off any necrotic tissueDress 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 infectionRe-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 bodyIf wound is deep and contaminated, it needs wide debridement in theatreIf not, use simple debridement and irrigationFollow-up is required Bites Cat and human bites are worstHigh risk of tendon injury and joint contamination leading to risk of septic arthritisMost require aggressive surgical management, often followed by delayed primary closure/healing by secondary intentionGive antibiotics for 5 days Others Gunshot wounds are usually treated with thorough debridement and delayed primary sutureFacial injuries should ideally be sutured by a plastic surgeon– use fine sutures and remove after 2-5 daysCrushed tissues need to be elevated for 7-10 days to reduce swelling prior to closure (risk of compartment syndrome) Here’s some questions What is the Parkland formula? Oops! This section is restricted to members. What is compartment syndrome? Oops! This section is restricted to members. Which wounds are high risk for tetanus? Oops! This section is restricted to members.