Wounds are a very common presentation to A&E and minor injuries departments. Wound management is very clinician dependent and there is a lot of variation in practice. It is important to be accurate when assessing and documenting wounds as it can have medico-legal implications, should your assessment later come up in a court case.

Depth

• Superficial involving only the epidermis
• Partial thickness involving the epidermis and the dermis
• Full thickness that goes beyond the epidermis involving deeper structures such as subcutaneous tissue, tendons and bones

Types

• Abrasions: Scraping of the skin resulting from an injury or irritation. They are often superficial injuries and heal without scarring.
• Cut/Incision: Wounds made by sharp objects. They have straight and well defines edges. They usually need intervention.
• Lacerations: A torn, jagged wound. Caused by blunt force on the skin.
• Penetrating Wounds: Small deep wounds caused by sharp objects, such as needles. This includes puncture wounds.
• Skin tear: Traumatic wounds, often seen in the elderly, involving the seperation of dermis from epidermis.
• Bites
• Burns and chemical Injuries

Wounds can either heal by primary intention when they are held together by artificial means, or by secondary intention when they heal spontaneously through granulation pulling the wound together.

• Haemostasis: The wound has to stop bleeding. In most cases this can be done by applying pressure, keeping the wound elevated or adding a tourniquet. Often wounds will have stopped bleeding pre-hospitally. If the patient is on a blood thinner, it may be worth reversing anticoagulation in the presence of a significant bleed.
• Imaging: If there is any suspicion of a foreign body in the wound, it needs to be X-Rayed. It will show radiopaque materials such as ceramics, metal and glass.
• Decontaminate: Any visible foreign bodies should be removed. This may need to be done surgically, especially if they are lodged in deeper structures.
• Debride: Remove any dead tissue which can be done for pincer forceps.
• Clean and irrigate: All wounds need to be thoroughly cleaned. They can be cleaned with saline or tap water (there is no difference between the two). If there is a lot of visible dirt the wound can be irrigated with a small bag of saline attached to a giving set and applying pressure to the bag.
• Consider antibiotics in
  • Bites
  • Soiled wounds
  • Puncture wounds
  • Open fractures
  • Foreign bodies
• Tetanus Prophylaxis
  • Tetanus-prone wounds include: Puncture wounds, foreign bodies, compound fractures, certain bites. Most domestic pet bites shouldn’t need Tetanus prophylaxis unless the animal has been around soil.
  • High-risk wounds include: Wounds with devitalised tissue and visibly dirty wounds with soil or manure.
  • There are both tetanus booster vaccines and tetanus immunoglobulins available depending on the wound or patient vaccine status. Guidance can be found in the Green Book, Chapter 30.

• Steri-strips
• Glue
  • Most wounds can be glued, but it depends on the clinical assessment of the wound.
  • Tell patients that the glue will naturally peel off in 5-10 days and to keep the wound dry, otherwise the glue will wash off. For paediatric patients, you can cover it with a dressing to avoid them picking at the glue.
• Sutures
  • There is a lot of variations in practice but for deeper dermal closure use absorbable sutures and for percutaneous closure, non-absorbable sutures are typically used such as ethylon, prolene, vicryl.
  • Advise that stitches should be removed in
    • Facial wounds: 5 days
    • Scalp Wounds: 7 days
    • Arms: 7-10 days
    • Lower limbs: 10-14 days
  • Advise that showering is preferable to bathing, not to rub salts, lotions, soaps, make-up over the scar and to change dressings often.
• Staples
  • Often used for surgical closure, but in the Emergency setting can be used to close scalp wounds under local anaesthetic.
  • Remember to advise patients to have their stables taken out.

There are certain wounds that are more complicated to manage and will need referral for further specialist intervention. These may vary depending on local resources available and you should consult your local protocol.

• Large wounds that will need prolonged repair or grafting.
• Open fractures that need to be seen by orthopaedics.
• Wounds on the nose, ears, eyelids, crossing the vermillion border of the lips.
  • Look out for hidden injuries such a septal haematomas as they will need antibiotics.
• Pre-Tibial Lacerations can be managed both conservatively and surgically but often need follow-up. Some hospitals have dedicated pre-tibial clinics.

Up to date: Basic Principles of wound management

Up to date: Skin laceration repair with sutures

Teach me surgery: Basic Wound Management

Royal Children’s Hospital Melbourne Wound Management Guidelines

Black Country Partnership NHS Trust Guidelines

Cynn Cornish, Helen Douglas, Wounds UK | Vol 12 | No 4 | 2016

Written by Dr. Rebecca Nielsen (FY2)