Management of Wounds

Overview

The goals of wound care include:

1. Closure of the wound
2. Prevention of infection
3. Provision of stable and adequate coverage
4. Minimization of the defect
5. Maximization of function

The steps in management of wound usually involve assessment → preparation → repair → follow-up

• Wound assessment
  • Life-threatening and limb-threatening injuries
  • Location, age, depth, width, length of wound, and extent of devitalized tissue
  • Degree of contamination (clean or dirty wound) and Sx of infection
  • Neurovascular and musculoskeletal injuries
    • Radiographs for fractures
    • Pulsatile bleeding (arterial) or dark oozing (venous). Assess circulation distal to wound
    • Nerve integrity and function
• Preparation
  • Tetanus prophylaxis
  • Antibiotics as indicated
    • Open fractures
    • Situations of infection
  • Local anaesthetic (Lidocaine or Bupivacaine with or without epinephrine)
  • Exploration to examine underlying structures
  • Irrigation of wound
    • Normal saline (50-100mL per centimeter of wound length)
    • High pressure or pulsatile irrigation is effective in remove foreign bodies and reduces the need for debridement
    • Cleaning with soap and water
    • Povidone-iodine or Chlorhexidine for wounds with risk of viral transmission. May impair wound healing by damaging neutrophils and macrophages
  • Hemostasis
    • Evacuate hematoma
    • Control bleeding with ligature or cautery
    • Mechanical hemostasis with local pressure, packing, or torniquet
    • Pharmacological hemostasis with Tranexamic acid (systemic) or Epinephrine (local)
    • Fluids and Blood products for resuscitation if shock
  • Debridement of non-viable tissue
    • Mechanical debridement, surgical debridement, biologic debridement, enzymatic debridement, autolytic
• Repair
  • Deep fascial layer with absorbable suture
  • Superficial layer properlly aligned and non-absorbable suture (monofilament)/staples/dermal glue
  • Primary wound closure: close within 6-8 hours of extremity injury and 10—12 hours for injury of the scalp and face (bacteria require 6-8 hours to reach 10^5/gram of tissue, the level necessary for infection)
    • Clean wound with low infection risk whose edges can be approximated without tension
  • Secondary wound closure: leave the wound to heal by secondary intention via granulation tissue (w/o approximating wound edges)
    • Infected wounds (SSI)
    • Wound at high risk of infection (with foreign body implanted)
    • Bite wounds
    • Wounds older than the time frame within which primarily closure can be safely performed
    • Large wounds that cannot be approximated without tension
  • Delayed primary closure: close wound after secondary intention has began
    • Contaminated wounds left to heal by secondary intention with no signs of infection after 3-5 days
    • Clean wounds with healthy edges present after the time frame within which primary closure can be safely performed
  • Non-primary wound closure
    • Skin grafts
    • Skin flaps
• Follow-up
  • Monitor for signs of infeciton
  • Remove suture early (4-5 days for face) or 7-10 days for other parts of skin

Wound preparation

Types of injuries and considerations

Tetanus prone wounds

Determining appropriate tetanus treatment

Repair

• When closing deep tissue layers:
  • Deep fascial layers or deep dermal layers should be closed since they contribute to the structural integrity of the wound
  • Closed suction drains can be used to decrease dead space
  • Suturing fat adds no benefit to wound strength or structure, so fat should not be closed

Absorbable vs non-absorbable suture

Monofilament vs braided suture

Suture examples and characteristics

Suture size

Continuous (”running”) stitch: a series of stitches connected in line and only a single suture is use. Variations include simple continuous and locking continuous stitches

• Advantages of continuous stitch
  • Quick
  • Less suture material used
  • Less foreign body in the wound
  • Evenly distributed tension
• Disadvantages of continuous stitch
  • Too much tension leading to wound ischemia
  • Fluid and bacteria can travel along the suture and spread infection
  • Entire suture must be removed in case of wound infection

Interrupted stitch: each individual suture is placed, tied, and cut separately from any others. Variations include simple, vertical mattress, horizontal mattress, and many others

• Advantages of interrupted stitch
  • Very secure closure (if one stitch fails the others can hold the wound togethre)
  • Bacteria are less likely to move along the suture line
  • Can remove individual stitches in the event of wound infection
• Disadvantages of interrupted stitch
  • Time consuming
  • More foreign body in the wound
  • Uses more suture

Staples: staples offer rapid closure with less precise tissue approximation. Placing sutures in the dermis can help improve approximation

Skin glue and adhesives: skin glue is ideal in areas of low wound tension (face and neck). It has equivalent results and complication rates as traditional sutures and is more comfortable for patients.

Tape: tape is easy to apply and comfortable. It leaves no skin marks. However, it can easily be displaced with moisture/drainage and can create inverted edges.

Follow-up

The wound should be monitored for signs of infection and sutures/staples left in place until the healing process has created enough strength.

Recommendations for removing sutures