Wound Management (General Principles)

Clinical assessment

Based on history of injury/onset and visual inspection of the wound. Assess: - Type of wound (laceration, abrasion, puncture, contusion, bite, burn). - Location, size, depth. - Edges (sharp/clean vs. irregular/ragged). - Presence of contamination or foreign bodies. - Signs of infection (redness, warmth, swelling, pus, odour). - Involvement of deeper structures (tendons, nerves, vessels, bones, joints). - Neurovascular status distal to the wound. - Tetanus immunization status.

Investigations

• Wound exploration (often under local anesthesia) to assess depth, contamination, foreign bodies, and involvement of deeper structures.
• X-ray: If suspected fracture or radio-opaque foreign body.
• Ultrasound: May help identify non-radio-opaque foreign bodies or fluid collections (abscess).
• Wound culture: If signs of infection present, especially if not responding to empiric treatment or severe infection.

Diagnostic criteria

Clinical identification of a wound requiring management.

Non-pharmacological management

• Hemostasis: Control active bleeding with direct pressure. Ligation or cautery may be needed for larger vessels.
• Anesthesia: Local anesthesia (e.g., Lignocaine 1% or 2%, with or without adrenaline depending on location - AVOID adrenaline in digits, penis, nose, earlobes) for exploration, cleaning, debridement, and repair.
• Cleaning/Irrigation: Thorough cleaning is paramount. Irrigate wound copiously with sterile Normal Saline or clean water to remove contaminants and debris. Can use antiseptic solutions like Chlorhexidine 0.05% or diluted Hydrogen Peroxide (3%) for initial cleaning of contaminated wounds.
• Debridement: Surgically remove all devitalized (dead) tissue, foreign material, and heavily contaminated tissue until healthy bleeding edges remain ('Surgical toilet').
• Wound Closure (Decision based on time, contamination, tissue viability):
• - Primary Closure (Suturing, staples, skin adhesives): For clean, fresh wounds (<6-8 hours, up to 12-24h in well-vascularized areas like face) with minimal contamination and viable edges. Use appropriate suture material and technique.
• - Delayed Primary Closure: For wounds >8 hours old, moderately contaminated, or where tissue viability is uncertain. Wound is cleaned, debrided, packed loosely with moist gauze, and observed for 3-5 days. If no infection develops, edges can then be sutured.
• - Secondary Intention Healing: For heavily contaminated wounds, infected wounds, puncture wounds, bites (most), abscess cavities, wounds with significant tissue loss. Wound is cleaned, debrided, dressed, and allowed to granulate, contract, and epithelialize naturally. May require later skin grafting.
• Dressings: Apply appropriate sterile dressing to protect the wound, absorb exudate, and maintain a moist healing environment (if needed). Options: Simple dry gauze, non-adherent dressings (paraffin gauze), absorbent pads, packing gauze for cavities.
• Immobilization: Splinting may be needed if wound is over a joint or associated with fracture/tendon injury.
• Elevation: Elevate injured limb to reduce edema.

Pharmacological treatment

• Tetanus Prophylaxis: Assess immunization status and administer TT booster +/- Tetanus Immunoglobulin (TIG) based on guidelines (clean minor wound vs. tetanus-prone wound).
• Analgesia: Paracetamol, NSAIDs, or opioids as needed for pain.
• Antibiotics (Prophylactic): Generally NOT needed for simple, clean, minor wounds closed primarily. Indications for Prophylaxis: Heavily contaminated wounds, bite wounds (see TRA004), open fractures (see TRA006), wounds with significant devitalized tissue, wounds penetrating joints/body cavities, wounds in immunocompromised hosts, delayed presentation (>8-12 hours).
• Antibiotics (Treatment): For clinically infected wounds (pus, spreading cellulitis, systemic signs). Choice based on likely pathogens and severity. Empiric treatment for simple skin infection often Cloxacillin or Amoxicillin. Broader coverage needed for bites, deep/complex infections (e.g., Amoxicillin/Clavulanate, or combination like Cloxacillin + Gentamicin or Ceftriaxone). Adjust based on culture results if available.
• Empiric antibiotic for grossly contaminated wound (UCG): Cloxacillin or Amoxicillin 500mg q6h (Adult); 125-250mg q6h (Child).

Monitoring

Monitor wound healing. Check for signs of infection (increasing pain, redness, swelling, pus, fever) - follow up usually 24-72h after repair/initial management. Assess suture removal timing (depends on location: face 3-5d, scalp 7-10d, trunk/limbs 10-14d, over joints longer).