The LSUHSC New Orleans Emergency Medicine Interest Group Presents The Student Procedure Manual

Wound Care and Dressings

by Gerald Falchook with
Patrick Hymel

Indications
Prerequisites
Equipment
Procedure
-Primarily closed wounds (lacerations)
-Partial thickness wounds
-Abraded skin
-Most commonly used dressings
-Cleaning
-Elevation
-Tetanus prophalaxis
Complications
Follow-up
Related Procedures/Tests
References

Indications

• Postrepair wound care requires subsequent application of appropriate wound dressings and assessment of possible tetanus prophylaxis.

Prerequisites

• The application of dressings and further wound care is preceded by stabilization of the patient, a medical history, and a physical examination. Some wounds will require imaging techniques to detect injury to bone or the presence of foreign bodies. Appropriate wound closure and application of topical antibiotics also precede the use of dressings.

Equipment

• Various dressing materials are available, and several factors should be taken into account when choosing the appropriate dressing. There are eight types of absorbent cotton gauze, each type defined by the number of warp and woof threads per square inch.
• The functions of the dressing include:
  • Absorption of wound exudates
    
  • Debridement of open wounds
    
  • Providing a protective barrier against exogenous bacteria
    
  • Exertion of pressure on underlying tissues.
• The optimum dressing should have a nonadherent surface, be permeable to gases, and have a capacity to absorb some fluid without inducing desiccation of the wound. The outer barrier should be impermeable to bacteria and other particulate matter but permeable to water vapor.
  
• A drying wound produces a thick, hardened scab that impedes the process of epithelialization. Excess fluid can lead to maceration of tissue and may be a potential culture medium for bacterial proliferation. Gaseous permeability is essential because epithelialization is greatly accelerated in the presence of oxygen.

Procedure

Primarily closed wounds (lacerations):

• With the exception of wounds located on the face, primarily closed wounds are covered by nonwoven microporous polypropylene dressings, which are attached to surrounding skin by wide strips of microporous tape with no reinforcing fibers (aka "paper tape"). In facial lacerations, the development of blood clots between the edges of sutured wounds is of greater concern than the danger of surface contamination. These clots are replaced by a healing scar that can be avoided by swabbing the wound with half-strength hydrogen peroxide, or saline every 6 hours, until the wound edges are free of blood.

Partial thickness wounds:

• Vapor permeable membranes are indicated for partial thickness wounds such as abrasions, bums, road rash, and ulcers. Wounds treated with vapor-permeable membranes fill with granulation tissue before reepithelialization of the defect.

Abraded skin:

• Use of hydrogen peroxide causes abraded skin to develop a scab that makes suture removal tedious and painful to the patient. Instead, the skin abrasion wounds and their edges should be swabbed with a water-soluble base, such as polyethylene glycol with mupirocin (Bactroban), that disrupts the wound exudates, encouraging their exodus from the wound. Permanent hyperpigmentation of abraded skin will develop unless photoprotection is utilized with a sun-blocking agent for at least 6 months following the injury.

***In all cases, it is important to keep the wound clean and dry during the first 24-48 hours following application of the dressing.

Most commonly used dressings:

• Sterile 4x4s (aka "fluffs")
  
• Packing (a tape dressing, stored in a bottle; => pack it into the wound with a forceps)
  
• Abdominal pads (aka "ABD" pads; these are BIG)

Cleaning:

• In addition to protecting the wound as described previously, it should be cleaned daily to remove crust formations. Daily swabbing with half strength hydrogen peroxide or saline rids the wound of debris and blood clots that form between sutured edges. Hydrogen peroxide should not be used after separation of the scab because it is toxic to the epithelium and may produce bullae. It is safe to bathe and get the wound wet 24 hours after the injury.

Elevation:

• Injured extremities should be elevated during the first 24-48 hours following injury. Elevation lessens edema, hastens healing, and mollifies pain.

Tetanus prophylaxis:

• Table 1 lists guidelines for identifying tetanus -prone wounds. However, the immunization status of all patients must be considered, regardless of severity of the wound. The usual incubation period of tetanus is 7 to 21 days but ranges from 3 to 56 days. Immunization should be given as soon as possible but can be given days or weeks after the injury. The dose of tetanus toxoid is 0.5 ml IM, regardless of the patient's age. Diptheria vaccination (dT) should be given along with tetanus toxoid. The dose of tetanus immune globin (TIG) is 250 units in patients 10 years old or older, 125 units in children ages 5 to 10, and 75 units in children under the age of five. A single injection of TIG provides protective levels of passive antibodies for at least four weeks. Tetanus toxoid and TIG may be administered during the same visit but should be injected with separate syringes at different sites. The application of Diptheria and tetanus toxoids is contraindicated by a history of neurologic reaction or a severe hypersensitivity reaction after a previous dose. Local side effects such as erythema and induration without tenderness do not preclude continued use. Severe Arthus-type hypersensitivity reactions to dT are indicated by high serum tetanus toxin levels. Patients with contraindications to tetanus toxoid but who have not completed primary immunization to dT and who have tetanus-prone wounds should be given passive immunization with TIG.

Table 1: Tetanus-Prone Status Identification

Complications

• Infection
  
  • The patient should be educated to identify the signs of wound infection and to distinguish signs of infection from the normal inflammatory response of the injury. Infection is indicated by redness, swelling, increased pain, fever, pus, or red lines progressing up an extremity. Injuries classified as high risk must be reexamined for infection 48 hours after the trauma regardless of its appearance.
• Other
  
  • Allergies to tapes and antibiotic creams
  • Hematoma formation as a result of excessive bleeding/oozing
    
  • Scarring
    
  • Cutaneous nerve damage

Follow-up

• Laceration wounds will seal themselves within 24 hours and will not require additional dressings. Most other wounds require a follow-up inspection by the physician or department that initially treated the wound. Follow-up intervals vary according to the severity of the wound (consult a resident).
• Hydrogen peroxide causes sutures to lose their color, and so decolorized suture indicates that the patient has complied with the recommended postoperative wound care regimen.

Related Procedures/Tests:

• Splinting
  
• Suturing
  
• Incision and drainage

References

1. Emergency medicine: concepts and clinical practice. 4t' ed. Eds. Peter Rosen, Roger Barkin. Mosby-Year Books, Inc.: St. Louis, 1998.
   
2. Emergency medicine: a comprehensive study guide/ American College of Emergency Physicians. 411 ed. Ed. Judith E. Tintinalli. McGraw Hill: New York,
   1996.