Traumatic wounds: cleansing and dressing

VOL: 97, ISSUE: 28, PAGE NO: 50 Christine Dearden is A&E consultant; Janice Donnell, RGN, RSCN, is a staff nurse; Jean Donnelly, BSc, RGN, PGDip. wound healing and tissue repair, is tissue viability nurse; Martina Dunlop, BSc, RGN, is an emergency nurse practitioner; Royal Hospitals and Dental Hospital Health and Social Services Trust, Belfast Infection and poor cosmetic outcomes are just two of the adverse effects that can occur as a result of the mismanagement of a traumatic injury to the skin. It is, therefore, vital that nurses involved in the care of patients with such injuries have excellent assessment and wound management skills. Infection and poor cosmetic outcomes are just two of the adverse effects that can occur as a result of the mismanagement of a traumatic injury to the skin. It is, therefore, vital that nurses involved in the care of patients with such injuries have excellent assessment and wound management skills. Wound cleansing and debridement The most important factor in the management of traumatic wounds is meticulous irrigation and debridement. Dead tissue, foreign debris, devitalised skin and haematoma must be removed to reduce the number of contaminating bacteria and deprive those that remain of their breeding environment. This helps to protect the patient from the spread of infection, including tetanus, and ensures that the remaining tissue is viable, with a good blood supply that should heal with minimal scarring. In superficial wounds, cleansing and debridement can be achieved through thorough irrigation and, if necessary, scrubbing or dermabrasion of the injured parts with a soft nailbrush, toothbrush or sponge. Scrubbing will cause increased tissue oedema and a decrease in host defences (Maklebust, 1996) but may be necessary to prevent tatooing with contaminants. It will be painful and requires adequate analgesia. Local anaesthesia, such as 1% lignocaine, may be useful (Heyworth, 1997), but Edlich et al (1988) highlight the importance of balancing the pain caused by dermabrasion against that experienced when the needle passes through the skin. Topical anaesthesia, such as 2% lignocaine, may also be of benefit, but there is a lack of research on its use in wounds. It is not licensed for this purpose, so it needs to be prescribed (Bianchi, 2000). General anaesthesia may be required in the case of deep wounds as the entire tract will need surgical exploration, cleansing and debridement to identify damage to deep structures. Devitalised tissue in the wound bed will significantly delay healing and, in some cases, prevent it. Sharp debridement is the quickest method to remove it, but this should be carried out only by an experienced and skilled indi-

Practice point Degreasing agents such as Swarfega can help to remove oil from the skin.vidual. the injured area should be irrigated with copious amounts of water or saline. However. This can be approximated by using a 35ml syringe and a 19-gauge needle. certain solutions may be useful in one-off situations. contaminated wounds. and hydrogen peroxide can be used to lift dirt and gravel from the wound surface. Trauma caused by scrubbing or dermabrasion may be minimised through the use of a fine-pore sponge (Rodeheaver et al. which showed that the force of the pressure used to cleanse the wound was more important than the type of solution used. The use of a plastic catheter can eliminate this risk. Practitioners must be accountable for their actions and . 1990). Another potential complication of high-pressure irrigation is exposure to cross-infection owing to splashback of irrigants. it may traumatise healthy tissue or drive bacteria further into the wound. needlestick injury to either the patient or the nurse is a hazard. The efficacy of high-pressure irrigation (50psi). Heyworth. including hypochlorites. 1975. Where sharp debridement is not appropriate. enzymatic agents. using a pulsatile jet. preferably warmed to 37[s7]C. If it is too low. This can be reduced by cupping a gloved hand around the wound (Chrisholm et al. overall. various topical applications can be effective. debris may remain. However. Antiseptics There is some debate about the use of topical antiseptic solutions that arises from research showing they are an ineffective cleansing agent. Although this method significantly reduced bacterial counts in devitalised. . This must be applied before the wound is irrigated with fluid. Research on the effect of antiseptics on traumatic wounds is not sufficient to direct practice. 1975). Asepsis is required only once all gross contaminants have been removed from the wound bed. However. soapy solutions such as chlorhexidine may be useful in removing congealed blood and dirt from hair. has also been tested. 1985). have toxic effects on tissues and delay wound healing (Brennan and Leaper. While it is clear that antiseptics should not be used as a routine cleansing agent. 1992) or using cup-like devices designed to prevent splatter. Irrigation In the first instance. others believe they may still have a role to play in traumatic wound management owing to their bactericidal properties (Thomas. This can probably be explained through the earlier work of Rodeheaver et al (1975). For example. . the percentage of gross infection was higher in wounds treated by high-pressure irrigation. alginates and hydrocolloids. so we suggest that all topical antiseptics should be used with caution. A study by Angeras et al (1992) found a lower incidence of infection in traumatic wounds that had been cleansed with tap water than those cleansed with saline. Brown et al (1978) found that. hydrogels. if it is too high. Recommended irrigation pressures range from four to 15lb per square inch (Rodeheaver et al.Practice point Antibiotic therapy cannot replace thorough cleansing and adequate debridement. the amount of pressure required to thoroughly irrigate a wound is open to debate. 1997).

medical staff may decide to suture up to within 12 hours of injury (it is important to follow local protocols) to limit scarring in a cosmetically important area. Good tissue approximation with minimal tension is fundamental to healing. Absorbable sutures are used to approximate the deeper layers of the skin. Primary closure is not an option if contaminants or devitalised tissue cannot be removed from the wound. staples. Staples are particularly useful for closing scalp wounds. In such cases. are useful for superficial lacerations that will not be under a great amount of tension or flexion: they are contraindicated in wounds overlying or near joints. skin tapes or adhesives (glues). The choice of suture material depends on the depth of the wound and type of tissue. it may be closed primarily using sutures.aware of the indications and contraindications of each antiseptic. it is infected or it is an old injury. Local anesthesia is not usually required. Sutures and staples Properly applied sutures promote wound healing and reduce the risk of sepsis by eliminating wound cavitations and realigning tissue planes and opposing wound edges.Practice point Application of friar’s balsam at the wound margin may help skin tapes adhere to the skin. . are less likely to cause tissue ischaemia and are associated with a lower rate of infection. for example with wounds to the face. especially if they become wet. Tissue glue Tissue glue is painless to apply and sets quickly once it makes contact with tissue fluid. Wound closure If the wound is clean. If this is not done a ‘dead space’ may be left within the wound. providing a focus for the formation of haematomas and infection. This may involve closing the wound with deep sutures as well as closing the skin. There is no indication for the use of catgut or silk in wound management. An inappropriately thick suture will result in more tissue disruption and foreign body reaction. enabling them to make an informed choice. it is useful for small cuts and lacerations. The main disadvantage of skin adhesives is that they may peel off. . Skin tapes Paper adhesive strips. Non-absorbable sutures are used for skin closure. such as Steristrips. Reverse-cutting needles are used to suture skin because they penetrate with ease. The smallest size suture material practical for the wound should be used. alternative options include delayed primary closure or not to close the wound at all but letting it heal by granulation (Table 1). Monofilament sutures such as nylon are inert and gentle on the tissue. it is important to ensure that the edges are approximated in the depths of the wound as well as on the surface of the skin. Fine sutures such as 5/0 or 6/0 are used to close wounds on the face and neck (Table 2). In deep wounds. It cannot be used .Practice point In certain situations. especially in children. The main benefits of skin tapes over sutures are that they are quick and fairly painless to apply. especially extensor surfaces. Round-body needles cause minimal trauma but do not penetrate the skin well and are therefore used for the closure of subcutaneous fat.

Topical streptokinase should be avoided in patients at risk of coronary artery thrombosis.Create a moist wound environment. Despite this and the prestated adverse effects. . .Allow gaseous exchange. as its disadvantages outweigh its benefits it is not recommended in A&E. the choice of dressing should meet the requirements for optimal wound healing (Thomas. The type of product that is chosen usually depends on the depth of tissue damage. Hydrocolloids are useful for wounds that produce a low to moderate amount of exudate. 1997). . Many modern dressings. However. however. Where this is the case. It is used solely to weld the surface of the wound. Hydrogels actively rehydrate devitalised tissue by donating water to the desiccated matter. This creates a moist environment that facilitates autolysis.Protect the wound from pathogens. but the efficacy of hydrogels is reduced in the presence of excess exudate. whereas tulles and cotton/gauze pads do not. Ultimately. such as alginates. then intravenous streptokinase should be withheld in favour of an alternative thrombolytic agent (Bux et al. which are to: . If a thrombolytic agent is required within six months of administering topical streptokinase/streptodornase. be used indiscriminately as misuse can lead to sensitisation and bacterial resistance. 1985). Antimicrobial dressings may be of some benefit in reducing bacterial colonisation. it is better to use a product such as an alginate to absorb the exudate and produce a gel. those near the eye or mouth. They should not.on lacerations greater than 3cm long. . meet these requirements. Enzymatic products such as streptokinase/streptodornase liquefy slough. they are also used to protect the injured/healing tissue and create optimal conditions for healing. deep lacerations or ragged lacerations.Provide a constant wound interface temperature. Morrison. hydrocolloids and hydropolymer foams. Wound dressings In the past. trauma and particulate matter.Control exudate levels. wound contact materials were used simply to absorb blood and exudate. hydrogels. However. the type of tissue in the wound bed and the level of exudate. Hypochlorite solutions such as Eusol are non-selective and will remove viable as well as non-viable tissue (Brennan and Leaper. Today. 1992). . the topical application of streptokinase has been shown to result in a significant production of antistreptokinase antibody. 1990. some plastic surgeons find hypochlorites useful in the preparation of an area for grafting.

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