Chapter 32. Wound management
Definitions
Abrasion – Removal of part of the surface of the skin. There is often oozing from the capillaries on the surface of the dermis. Conventionally referred to as a ‘graze’
Avulsion – The forced separation of two parts; with wounding, this is when a flap of skin and associated tissue has been partially or completely removed
Amputation – Removal of a portion of a limb or the complete limb
Closed wound – An internal injury caused by a blunt direct force to the surface of the body. The skin itself is intact but there is injury to the underlying tissues
Cut (incised wound) – A breach of the skin caused by a sharp edge
Contused wound – Loss of continuity of the tissue with surrounding bruising
Contusion – An area of bruising due to the effect of a blunt force
Haematoma – An accumulation of blood due to bleeding beneath the skin as a result of a blunt direct force
Healing by primary intention occurs when the edges of the wound are already adjacent or can be brought together (e.g. with sutures or Steri-Strips)
Healing by secondary intention occurs when there is significant tissue loss from the wound and regrowth of skin cover is required. With secondary intention healing wound contraction is more prominent. This can lead to significant deformity or contractures if the defect has been large
Laceration – A tear of the skin caused by a blunt force; it is usually irregular in shape
Puncture wound – A wound with a narrow path made by, for example, a nail
Wound – Any interruption by violence or surgery of the continuity of the external surface of the body or the surface of an internal organ. Strictly, a wound is a disruption of the continuity of tissue.
Factors affecting wound healing
• Age
• Nutrition
• Diseases
• Drugs
• Infection
• Foreign body
• Poor blood supply
• Adhesions, movement and drying
• Ionising radiation
• Hypoxia
• Psychological stress.
Immediate management of wounds
The primary survey comes before dealing with any soft tissue injury.
If there is a penetrating wound to the chest the object must be left in situ (if it has not already been removed).
If there is an open pneumothorax, an Asherman® or Bolin® chest seal or a dressing sealed on three sides must be placed over the wound, thus preventing a sucking chest wound.
Control of external haemorrhage
There are three different kinds of bleeding:
• Arterial
• Venous
• Capillary.
Direct pressure
Constant direct pressure is applied to the wound with a clean, large gauze pad (dry or moist). If a gauze pad is not immediately available a gloved hand can be used initially.
Several layers of gauze can then be placed on the wound and a bandage placed over these layers of gauze to secure them in position.
Elevate the injured area above the heart to reduce blood flow to the area.
Indirect pressure
If the wound is still bleeding, the dressing should not be removed but may be reinforced with further dressings.
If the wound continues to bleed through the dressings indirect pressure may be applied to pressure points.
Five important pressure points are:
• The femoral artery in the groin, which can be compressed against the pelvis