Wound Care

 

VBMC TRAUMA CARE SERVICES GUIDELINE

Wound Car

            Wound care is much easier than most physicians and nurses think. The process has become unnecessarily complicated, confusing, and expensive. The simple answer is soap, water, and gentle handling of tissues. Put them in the shower! Except for early clean wounds (see below), most all patients should be in the shower within a couple of days of operation. Astringents (peroxide, betadine, acetic acid, alcohol, Daken’s, etc.) should rarely if ever be used in a wound. There is a widely held misconception that more frequent wound care somehow makes wounds heal faster. This is simply not the case. Keeping wounds clean, moist, and covered allows the body to heal the wounds considerably faster. Astringents, frequent dressing care, and overzealous packing are more often responsible for delays in healing.

Surgical Wound Classification

Clean Wounds - These are surgical incisions that follow an elective surgical procedure that does not involve the aerodigestive tract. Examples would be neurosurgical procedures, vascular procedures, hernias and most elective orthopedic procedures. 

Clean contaminated wounds – These are surgical incisions that follow an elective surgical procedure that crosses the aerodigestive tract. Examples would be most ENT procedures, operations on the gastrointestinal tract, or operation on the lung.

Contaminated wounds – These are incisions that follow an emergent surgical procedure where there is obvious or potential infection. Examples would be perforations of the GI tract, strangulated hernias, complicated soft tissue infections, open fractures. 

Dirty wounds – This is really a matter of degree. The difference between contaminated and dirty wounds is really the degree of contamination. Complex wounds with large, devitalized areas, gross fecal contamination, large amounts of purulent material, dirt, foreign bodies etc. are usually classified as dirty.

Important Definition

            Dehiscence refers to separation of the wound edges. Dehiscence can further define as involving the skin and subcutaneous tissue (superficial) or extending to the deeper layers (fascial dehiscence). Evisceration refers to the protrusion of visceral contents through the wound. Not all dehiscence has evisceration but all eviscerations have dehiscence.

Wound management

Wounds are managed in one of three ways: 

1.            Primary closure of the skin and subcutaneous tissues (most wounds) 

2.            Delayed primary closure. Wounds are left open initially. The skin is then closed primarily between day 3 and 4. Bacterial counts are lowest in the wound at this point and delayed primary closure has the greatest success. 

3.            Healing by secondary intention. This technique applies for most open wounds.

Closed wounds

            Wounds that have been closed primarily will seal within 36 hours. After that point it is very unlikely that environmental contamination would compromise the wound. The general rule is to leave the surgical dressing on for 24 hours. After that point the wounds can be covered with a light dry dressing to absorb minor drainage, prevent irritation and for patient comfort. These wounds should be carefully inspected at least once a day for signs of infection (redness, swelling, excessive tenderness, purulent drainage). The subjective patient complaint of wound pain (fever may or may not be present) that increases or is out of proportion to wound size is often the earliest sign of surgical wound infection.

Open wounds

            Contaminated or dirty wounds are often packed and left open. The main clinical reason for this practice is to avoid the high incidence of wound infection if the wounds are closed. The wounds are generally packed tightly to achieve hemostasis after the initial operative procedure. Unless there is a planned return to the operating room for exam under anesthesia, further debridement, and irrigation, these dressings should be taken down and the wound examined at 24 hours. The first dressing change can be quite painful, and provisions should be made for adequate analgesia prior to proceeding. Most of the pain emanates from the densely innervated wound edge and care should be taken in this area. If the dressing is adherent gentle wetting with saline will facilitate removal and reduce discomfort. “Clean wound” care rather than “sterile technique” should be the standard practice. At the first dressing change the decision can be made to initiate saline wet to dry dressing or application of a vacuum dressing. At this point a decision can also be made about washing/showering the wound with soap and water. Dressing changes need only be once or twice a day and packing of the wound should be gentle. Saline irrigation of the wound base is permissible. As mentioned previously, astringents should be avoided, and every effort should be made to avoid wound desiccation by irrigating the wound in between dressing changes if necessary. 

            Regarding dressing fixation, the skin should be protected from tape adhesives by using duoderm or by application of Bandnet dressing (preferred). Absolutely every effort should be made to simplify wound care prior to discharge. Patients should be given clear instructions on clean wound care; showering should be encouraged. When possible, wounds can/should be dressed in tap water rather than sterile saline which is considerably more expensive and unnecessary for most wounds.

Open wounds and evaporative water loss.

            Open wounds can and do result in significant fluid & electrolyte disturbances. Dehydration from evaporative water loss and malnutrition from protein loss are significant problems with large wounds. This can be amplified if the wound is associated with an enterocutaneous fistula. The patients should be assessed for signs of volume depletion such as excessive thirst, diminished skin turgor, and or low urine output. Keeping the wounds covered and moist reduces evaporative water loss and may reduce protein loss as well.

Wound infection

            The earliest and most frequent sign of wound infection is excessive wound pain and tenderness. Low grade fever, wound redness, and drainage often appear later and can be easily seen with a good exam and dressing change. Wounds should be opened in the affected area to allow drainage, irrigation, and gentle packing just like in open wounds. Wound culture and antibiotics are totally unnecessary except in rare circumstances such as when patients exhibit signs of systemic illness and/or there is prosthetic material in the wound. WARNING! When dealing with abdominal wall wounds, drainage may indicate deep wound problems such as fascial failure and/or evisceration.