Wound Management



Wound assessment

History

  • Time it occurred
  • Mechanism of injury
  • Pssibility of foreign body
  • Loss of function of structures beneath
  • General factors
    • a history of diabetes
    • steroid therapy
    • peripheral vascular disease
    • Ask about tetanus status
  • Any wound on the hand must lead to enquiry about profession and whether the patient is self-employed

Examination

Examine to detect INDIVIDUAL structures that could be damaged (e.g. tendons, nerves), for the presence of dirt, foreign bodies and the displacement and loss of tissue. (e.g. use "DP" or "FDS" not "tendons" intact)

Check the skin edge of viability.

If a skin flap has been raised record the dimension in terms of width, length and orientation of the base of the flap.

Make an accurate record of your clinical findings.


All Wounds caused by glass must always be x-rayed.


Treatment

Thorough mechanical cleaning is essential for all wounds, e.g. for dirty hands get the patient to use tap water [BestBets], Hibiscrub himself or Swarfega if grease is present. Remember to use scrubbing/toothbrushes if necessary. Local anaesthesia will probably be required to assess and clean the wound thoroughly.

Wounds may be closed by:

  • Primary suture - for clean wounds less than 6 hours old
  • Delayed primary suture - 3-4 days for wounds that are potentially infected - daily dressings required

1º closure should be used for clean incised wounds that can be closed tension free.

Wounds should not be closed if they are dirty, old, if there is a possibility of a foreign body, crush injury, cannot be closed without tension or are due to a bite (except on the face) - use DELAYED 1º closure. Clean and dress the wound and review it at 48 hours. If it is not infected then close it between days 2 and 5.


Suturing

Wound Suture Removal days
Scalp 3/0   4/0 7
Face 5/0   6/0 4 - 5
Anterior trunk 4/0 7 - 10
Posterior trunk 3/0 7 - 10
Upper limbs 4/0 7 - 10
Hands 5/0 7
Lower limbs 3/0 10 - 14
Extensor surface joints 14
  • The wound should be sutured so that at the end it is completely closed throughout its depth and length
  • Avoid any dead space. (achieved with vertical mattress stitches without tension) with 5/0 Vicryl
  • Interrupted suture should always be used
  • The knots should be placed to one or other side of the wound and must not be tied tightly to allow for swelling
  • Knots should be placed at least 2 mm from the skin edge and 3 mm apart (hand)
  • All suturing is the responsibility of the SHO / ENP treating the patient. 
  • When medical students or dental students suture, the assessment of the wound and suggestion for suturing must be made by the SHO / ENP who will also need to check the wound after suturing
  • Remember sutures on extensor surfaces of joints need to stay in longer and the joint may need immobilisation to produce a good scar
  • Record the number of sutures inserted as this helps nurses/patients when they remove them
  • If the patient is referred back to the GP's Practice Nurse for removal of sutures, the number, type and date of removal must be indicated in the GP letter given to the patient

Infected wounds ( Do NOT suture closed)

Remember the importance of immobilisation and elevation in the treatment of sepsis, e.g. high sling for hands. Take a swab to identify the organism in every case.


Wound packing

Wound cavities are not to be packed as this maintains a cavity, traps infection, increases scarring and slows healing. The aperture is kept open by means of a small plastic corrugated drain or wick to allow the cavity to heal in and simultaneously discharge unhealthy material. Alternatively an elliptical incision will keep the aperture open.

Please drain rather than pack.


Bites (animal and human)

Please see the Bites management page.


Abscesses

  • An abscess is a contained infection which is treated surgically
  • Antibiotics are only required if there is cellulitis or lymphadenopathy spreading from the focus of infection

Cellulitis

  • Cellulitis is usually caused by streptococci or staphylococci
  • Treatment is as per NCHD.ie
  • On presentation mark the area of cellulitis, look for lymphangitis, lymphadenitis and pyrexia. The presence of these features or spreading cellulitis require referral and hospital admission
  • Check and record capillary blood glucose (Beware of diabetic or immunocompromised patients)

If the area is small, the patient is sent away with a course of antibiotic and reviewed at 24 hours (GP).

If the cellulitis has increased that is an indication for admission for elevation of the affected part and IV antibiotics.

Diabetic patients who are well but have a small area of cellulitis should be treated with Ciprofloxacin and reviewed early.

Antibiotic policy

  • Do not give prophylactic antibiotics
  • Thorough cleaning and debridement of the wound is needed
  • Antibiotics (NCHD.ie) are only indicated for tetanus prone wounds (as per "Bites") or after appropriate micro. sensitivity tests or
    • Potential joint involvement
    • Lacerations of the palm or sole (note no conclusive evidence for penetrating wounds to the sole) [BestBets]
    • Tetanus prone/contaminated wounds
    • Patient diabetic/immunosuppressed
  • Incision and drainage is the treatment of choice when pus is present


Content by Dr Íomhar O Sullivan. Last review Dr ÍOS 12/08/22.