Wounds
Wounds section
Wound assessment
History
- the time it occurred
- the mechanism of injury
- the possibility of foreign body
- any 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 structures that could be damaged (e.g. tendons, nerves), for the presence of dirt, foreign bodies and the displacement and loss of tissue. 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 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)
- Infection is a very real risk
- The mouth harbours many organisms
- The wounds have contused tissues in addition to the lacerations
- Therefore, thorough cleaning often using irrigation with H²O²
- Excision of damaged tissues is often necessary
- Do not close except in facial wounds
- Delayed primary suturing prevents wound complications
- Large wounds can be partially closed, particularly the subcutaneous tissues.
- Antibiotics are indicated [Bestbets,
NNT 14], for human bites and all bites to the hand. [Cochrane]. If in doubt discuss with Duty Doc
- Initially Co-amoxiclav is usually sufficient BUT swab all bites and review the patient in 2 days.
- The bacteriology result will then be available to guide you for more antibiotics if necessary.
- Remember - rest and elevation.
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 with Penicillin and Flucloxacillin together (500 mg QDS).
- 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 BM (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.
If the cellulitis has increased that is an indication for admission for elevation of the affected part and intravenous 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
- Co-amoxiclav is only recommended for bites and penetrating wounds (e.g. after standing on a nail) or after appropriate sensitivity tests from the microbiology department
- Penicillin and Flucloxacillin are recommended for cellulitis
- Incision and drainage is the treatment of choice when pus is present.
Conditions requiring antibiotic treatment
- Human or animal bites (rarely needed in head / neck wounds)
- Penetrating lacerations overlying joints or fractures
- Lacerations of the palm or sole
- (note no conclusive evidence for penetrating wounds to the sole) [BestBets]
- Contaminated wounds
- Cellulitis / lymphangitis
- Wounds in
- insulin-dependent diabetics or
- those on steroids immunosuppressed
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