This is a presentation i prepared and thought some folk may like to read it.
WOUND MANAGEMENT
A large part of the first aider’s workload entails the management of acute traumatic wounds.
Wound care involves good knowledge of skin anatomy, the physiology of wound healing, the impact of infection on healing, and the provision of self-care advice to patients who can manage their own wounds (Holt 2000).
Wounds for approximately 25-30 per cent of the total workload of an A&E department (Wardrope and Smith 1992). The commonest wounds presenting to the A&E department are lacerations caused by blunt trauma (Wardrope and Smith1992), cuts, abrasions and burns, all of which usually respond rapidly to treatment and heal without complication (Dealey 1999). With this statistic we can estimate that 25-30% of the first aiders work is similar but there has been no statistical evidence to tell us if this is a fact.
What is a wound?
A wound signifies a break in the continuity of tissues covering the body and is usually associated with a loss of substance (Lippert 1999). In traumatic and intentional injury, there is a rupture of the blood vessels, resulting in bleeding, followed by clot formation (Dealey 1999). The type of trauma and extent of damage serve to further classify wounds for prognosis and treatment options.
Different types of wounds
• Cut (incised wound, incisional wound) – a breach in the skin caused by a sharp edge, such as a kitchen knife or glass. The wound edges are well defined and are often straight, with little soft tissue bruising
• Laceration (Latin lacerare – to tear) – a breach in the skin caused by a blunt instrument/force. The wound is irregular, with tearing of the tissues. It often occurs as a result of a fall, a blow from a blunt object, or a crushing force
• Contused wound – a breach in the skin, with surrounding bruising
• Contusion – an area of bruising due to a blunt force, without a break in the skin
• Haematoma – a subcutaneous collection of blood giving rise to a fluctuant swelling
• Penetrating wound – a wound with a fine path made by a pointed object, for example, railing spike, knife, rusty nail (After Critchley 1978)
Triage
At triage, the first aider will assess the patient and document the examination and findings on the injuries log. This examination and subsequent description of the wound is vital for the correct management of patients with acute injury, no matter how small.
There are three key elements to consider at triage:
• Accurate description of the wound.
• Documentation of mechanism of injury, tetanus immunisation status, current medication and known allergies.
• First aid measures for haemostasis (stopping of blood flow), proper cleansing and adequate temporary closure of open wounds, which will lengthen the time available for definitive management by First Aid post, the A and E department or the ambulance service.
Wound Assessment
The ability to make an accurate assessment of a wound is an important first aid skill (Dealey 1999). It should be carried out as part of the holistic approach to patient care in every first aid setting.
Assessment a Wound
• Anatomical site
• Size of wound (width, length)
• Depth of wound (gently probe)
• Configuration (flap, jagged)
• Tissue loss
• Deformity
• Loss of function/actual motor or sensory loss
• Pain
• Hand dominance(where relevant)
• Haemorrhage(actual and estimated)
Wound/ Patient History
In the first aid environment, the first aider will be the only person to get a detailed history from the patient while assessing and cleaning an acute wound.
Adequate history taking should include:
• Time since wounding.
• Circumstances of injury/mechanism of injury.
• Tetanus immunisation status (DoH 1996).
• Allergy – hypersensitivity to adhesive tapes, dressing materials and medications.
• Current/recent medication – corticosteroid therapy, aspirin and other anti-coagulant therapy.
• Social history – to ascertain whether the patient is able to manage to get themselves home, or has family who can assist in the management of the wound following the injury.
• Psychological problems – those associated with wounding should never be underestimated; a patient with a facial laceration or cut might well be traumatised as a result of altered body image.
Good wound management requires an accurate assessment along with a detailed history. Following careful assessment and evaluation of the patient, all findings should be documented on the patient’s documentation and forwarded with them to the ambulance service , so they can forward it to the A and E department
.
Diagrams, measurement tools, such as grid paper, clinical rulers, or even photographs maybe used to record the findings. Once this is complete, the wound can be actively managed.
Suggested History information that could be taken:
• Hours since wounding
• Mechanism of injury
• First aid treatment, if any
• Tetanus immunisation status(DoH Guidelines 1996)
• Allergy history, including medications
• Current/recent medication; remember steroid therapy
• Social history (Family, Next of Kin)
• Lifestyle/risks (Alcohol consumption, smoking)
• Psychological assessment
• Age and occupation
Wound Cleansing
Wound cleansing is essential for the prevention of infection, tattoo scarring and to exclude foreign body contaminants, such as grit (Holt 2000). Wound infection is the most common serious complication of a simple laceration (Moscati et al 1998). During wounding there is a breakdown in the protective functions of the skin and microorganisms can enter the deeper tissues and cause infection (Courtenay and Butler 1999).
Expensive surgical dressings, tissue adhesive, strip closures, staples or sutures will not assist healing if wounds are not properly and thoroughly cleansed initially. However, Hollander et al (1998), in a study exploring infection rates for face and scalp wounds, found that there was no difference in the outcome for patients who had wound irrigation prior to skin closure and those who did not. The patients included in the study had non-bite, non-contaminated facial or scalp lacerations that were less than six hours old. This finding can only be generalised to facial and scalp wounds, which are closed within a short time of initial wounding. While Moscati et al (1998) and Holt (2000) would suggest that all traumatic wounds should be considered contaminated, it is not possible to clinically differentiate on examination which wounds are at risk because some will appear clean, while others will be obviously contaminated.
Historical data collected by the first aider about the wound will alert the medical team to the possibility of potential contaminants, bacterial load, foreign body and healthiness of wound margins, but an assumption should be made that all traumatic wounds contain significant amounts of bacteria and must be decontaminated (Chisholm 1992, Moscati et al 1998). Wounds that have ingrained dirt such as deep abrasions (road rash), especially to the face, might need scrubbing and debridement under anaesthetic.
These wounds, although seemingly minor in nature, have the potential to cause long-term tattooing and scarring and, therefore, might require the skills of the plastic/reconstructive team to be managed optimally.
Management options
What to use to clean a wound?
Irrigation of the wound is essential to remove contaminants and reduce infection rates. Topical antiseptic solutions have been discredited recently, with normal saline coming to the fore as the optimum cleanser (Holt 2000, Moscati et al 1998, Walsh 1999).
However, some recent studies have shown that ordinary tap water of drinking quality has proved as effective at irrigating and cleansing wounds as normal saline solution (Angeras et al 1992, Moscati et al 1998, Riyat and Quinton 1997). Antiseptic solutions such as cetrimide and chlorhexidine claim to destroy bacteria and have a detergent effect on wounds. Holt (2000) reports that most of these solutions require 20 minutes contact time with bacteria to have an effect. There is little evidence to support the continued use of iodine solution as a first-line method of wound cleaning; it is not recommended for routine cleansing or prophylaxis due to its cytotoxic side effects on acute and healing wounds (Holt 2000). Other solutions, such as hydrogen peroxide, were previously thought to have decontaminating and desloughing properties, but these properties are greatly reduced once the solution is in contact with blood and pus (Holt 2000).
Also, the thermal effect of the solution adversely affects healthy tissue. Most of the recent literature on wound cleansing and choice of solution seems to suggest that irrigating wounds with normal saline solution or tap water offers financial and therapeutic benefits and has become the treatment of choice for cleansing many types of wounds (Dealey 1999).
How does a wound heal?
The healing of every wound takes place in phases that overlap in time and cannot be separated from one another (Lippert 1999). The usual division into three or four wound-healing phases is described in detail in most wound management texts (Courtenay and Butler 1999, Dealey 1999, Flanagan 1997, Holt 2000, Lippert 1999). It is important that first aiders are aware that many wounds might show evidence of more than one wound-healing phase concurrently.
Healing by primary and secondary intention
Wound healing has long been classified into healing by primary intention and by secondary intention. The word intention refers to the physician’s intention to achieve primary wound healing with wound edges close together and with few gaping wound margins (Lippert 1999).
Healing by primary intention includes delayed primary healing, which occurs when an infection is anticipated; in this case the wound would not be closed definitively with sutures or closure strips. The wound is dressed and observed for evidence of infection, until at approximately four to seven days, if no infection is apparent, the wound can be sutured or closed with strips and allowed to heal by primary intention.
If an infection occurs, the wound is classified as healing secondarily and receives treatment as for an open wound. Secondary wound healing always occurs when tissue gaps have to be filled or when a purulent infection prevents direct union of the wound edges (Lippert 1999). The less damage caused to the tissue, the more favorable the conditions for wound healing.
Many simple, superficial cuts (incision wounds) seen and treated in the A&E department are suitable for healing by primary intention due to ease of wound apposition and negligible loss of substance. Wounds that result from blunt trauma are often suitable for primary closure after surgical debridement.
However, there are some wounds resulting from tearing or blunt injury that are more suited to delayed primary closure or healing by secondary intention, for example, crush injury to the pulp of the fingertip or wounds heavily contaminated and more than 12 hours old (Wardrope and Smith 1992). Patients with blunt injuries sustain larger amounts of kinetic energy, resulting in micro vascular disruption, oedema and devitalized tissues (Chisholm 1992).
Other factors that might influence healing are:
• Anatomical site: areas such as the pretibial (shin) are often slow to heal due to poor blood supply and friable nature of the tissue.
• Vascular supply: the rich vascular supply to the face and scalp ensures speedy healing. If patients have underlying peripheral vascular disease, wounds might heal more slowly.
• Movement: a wound over a joint, especially over extensor surfaces, will take longer to heal.
• Method of closure: good technique with careful tissue handling is essential to a successful outcome; vigorous scrubbing of wound edges to remove grit can cause further tissue damage.
• Wound configuration: jagged wounds with large areas of skin loss or devitalised tissue will heal at slower rates than simple uncomplicated wounds.
• Mechanism of injury: incised wounds heal quicker than lacerations from blunt trauma, as there is less destruction and tissue oedema.
• Delay in management: delays in decontamination and definitive management will cause wound contamination, infection and delayed healing.
• General health and nutrition: vitamin C and zinc deficiencies can lead to poor wound healing. Older patients might have underlying disorders of vascular and endocrine systems that influence healing. Medication such as corticosteroids might bring about changes in the structure of the skin and influence wound healing rates (Thomas1997).
Tetanus immunisation status
All patients with wounds must have their tetanus immunization status established (Wardrope and Smith 1992). Clostridium tetani is an anaerobic organism and thrives in conditions where there is devitalized tissue and haematoma formation.
Two questions are essential when assessing the further need for tetanus immunisation:
• Has the patient been immunised according to Department of Health recommended guidelines (DoH 1996)?
• Is the wound clean or tetanus-prone?
Minor wounds that commonly present to a first aider department generally heal rapidly and patients return to normal activity quite quickly. However, there are always exceptions to this rule and it is the first aider can influence the outcome of this group of people. Adequate knowledge about wounding, wound assessment and management strategies will improve the outcome for a significant number of people who just have ‘a simple cut’.
REFERENCES
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http://www.smtl.co.uk/World-Wide-Wounds
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Factors that influence wound healing
