Wound hygiene (eg, cleansing, irrigation, and debridement), including thorough examination of the wound and surrounding tissues, promotes uncomplicated healing of traumatic skin wounds and is required prior to wound closure.
Wound healing can be impaired by various factors (eg, bacterial contamination, foreign bodies, wound ischemia, host factors). All traumatic wounds are assumed to be contaminated. The goal of wound hygiene is to reduce the contaminant burden without causing further tissue damage or introducing more contaminants.
Diagnosis and management of foreign bodies in wounds are a critical part of wound hygiene. Occasionally, identified or suspected foreign bodies are deeply seated, requiring consultation by a surgical specialist.
Factors That Interfere With Wound Healing
Factor | Examples |
|---|---|
Tissue ischemia (due to features of the wound or locally poor circulation) | Disorders affecting peripheral vasculature (eg, diabetes, arterial insufficiency) Type of injury (eg, a crush-type injury, which damages the microvasculature) Repair techniques (eg, overly tight sutures) Use of cautery |
Bacterial proliferation | Wound hematoma Foreign material (including deep dermal suture material) Delayed treatment (eg, > 6 hours for lower-extremity injuries; > 12 to 24 hours for face and scalp injuries) Significant wound contamination (as typically occurs in bite wounds) |
Medications | Antiplatelet medications and anticoagulants Medications that suppress inflammation (eg, glucocorticoids, immunosuppressants) |
Comorbidities | Disorders that suppress the immune system or impair healing (eg, chronic kidney disease) Undernutrition (eg, protein-calorie undernutrition, deficiencies of specific nutrients such as vitamin C) Disorders of collagen synthesis (eg, Marfan syndrome, Ehlers-Danlos syndrome) |
(See also Lacerations. )
Indications for Wound Care
Traumatic skin wounds
Contraindications for Wound Care
Absolute contraindications
None
Relative contraindications
Wounds of highly vascularized skin (eg, scalp and face) that are not grossly contaminated may not need irrigation (1, 2).
Deep wounds or those with sinuses or fistulas should be carefully evaluated before irrigation to avoid retention of foreign material or seeding of bacteria deeper into the wound.
Puncture wounds should be irrigated and debrided at the surface. However, deep probing, irrigation, and coring is not indicated (3). Deep probing without visualizing the depth of the wound may force foreign material deeper into the wound. If foreign material is suspected but not seen on superficial inspection, surgical exploration should be performed.
Actively bleeding wounds should not be irrigated, because irrigation may disturb clot formation; obtaining hemostasis must precede irrigation.
Wounds involving certain structures (eg, nerves, blood vessels, ducts, joints, tendons, bones) and those covering large areas require specific repair techniques that may necessitate care by a surgical specialist to ensure that function is preserved and to achieve the best possible appearance of the healed wound. Hand lacerations or injuries, particularly high-pressure injections or those requiring microscopic repair procedures, require surgical consultation. Facial lacerations, deep or complex wounds, or wounds involving the eyelids also usually require specialist consultation.
Imaging studies (eg, radiographs and ultrasound) should be obtained for deep wounds, puncture wounds, and other wounds that potentially involve a fracture or may contain foreign bodies (eg, teeth, glass, or splinters). CT as well as MRI can help locate foreign bodies, particularly when their location in relation to underlying structures is important.
Complications of Wound Care
Infection, the risk of which is increased by insufficient cleansing or debridement, overly aggressive wound hygiene that results in seeding bacteria deeper into the wound, foreign body retention (especially wood splinters or other organic material), or overly aggressive debridement of viable tissue
Further tissue damage due to overly aggressive wound hygiene
Equipment for Wound Care
Wound hygiene and closure are not required to be performed under sterile conditions. Instruments that touch the wound (eg, forceps, needles, suture) must be sterile. Clean single-use nonsterile gloves as well as clean but not sterile water may be used in immunocompetent patients.
Clean procedure, barrier protection
Appropriate personal protective equipment (eg, face mask, safety glasses or a face shield, head cap, gown, gloves); sterile gloves may be used if preferred but are not required (4, 5).
Sterile drapes, towels (for wound debridement and suturing)
Wound cleansing, inspection, debridement (not all items are required for simple wound repairs)
Overhead procedure light
Antiseptic solution (eg, chlorhexidine, povidone-iodine)Antiseptic solution (eg, chlorhexidine, povidone-iodine)
Pneumatic tourniquet (or blood pressure cuff) and hemostatic agent, as needed to assist with hemostasis
Local anesthetic (eg, 1% lidocaine or 1% lidocaine with epinephrine 1:100,000, 25-gauge needle); local anesthetics are discussed in Local anesthetic (eg, 1% lidocaine or 1% lidocaine with epinephrine 1:100,000, 25-gauge needle); local anesthetics are discussed inLacerations
For certain patients (eg, children), topical anesthetic (eg, proprietary emulsions of 2.5% lidocaine plus 2.5% prilocaine)For certain patients (eg, children), topical anesthetic (eg, proprietary emulsions of 2.5% lidocaine plus 2.5% prilocaine)
Sterile saline for irrigation (sterile water or clean, potable water are permissible substitutes)
35-mL and/or 60-mL syringes
Irrigation shield (syringe attachment to block splashing)
Plastic catheter (eg, 18- or 19-gauge standard catheter) or combination irrigation/splash guard device
Basin
Sterile gauze squares (eg, 10 cm × 10 cm [4 inch × 4 inch])
Fine-pore sponge (eg, 90 pores per inch)
Tissue forceps (eg, Adson forceps), tissue hook, probe, hemostat, splinter forceps (fine-tipped), and suture scissors (single blunt-tip, double sharp edge)
Scalpel (eg, #10 for large incisions, #15 for precise incisions, #11 for small stab incisions) or iris scissors for debridement
Wound dressing
Antibiotic ointment: Topical antibiotic ointments are recommended for sutured wounds because they help keep wound edges moist and prevent dressings from adhering to tissue; however, they have not been proven to reduce infection or enhance healing (6)
Sterile nonadherent, absorbent, and/or occlusive dressing
Gauze roll and tape or gauze sleeve
Sometimes splints or other materials to restrict motion or skin tension that may pull on the wound
Additional Considerations for Wound Care
Adequate anesthesia is important because these procedures may be painful, and insufficient anesthesia may result in insufficient cleansing, inspection, and debridement. Always perform the neurovascular examination (distal to the wound) before giving anesthesia.
Hair removal around the wound is generally not recommended, except when closure using adhesive strips is anticipated. If hair is removed, clipping rather than shaving reduces risk of wound infection (7). For wounds in the area of the eye, eyebrows must remain intact to achieve accurate alignment of wound edges during suturing.
Wound tissue can be vulnerable to further injury during cleansing and closure. Do not use excessive force during irrigation and debridement. To avoid crushing tissue, never grasp it with a hemostat or other high-pressure instrument.
A retained foreign body in a wound is suggested by history of how the wound occurred or by pain or foreign-body sensation (enhanced by motion) in the absence of infection.
Suspected foreign bodies can often be identified using ultrasound or other imaging studies.
Some foreign bodies (eg, small fragments of glass or metal in a puncture wound) may be allowed to remain in a wound if removal would incur additional tissue damage and further impair healing. Patients should be told that a retained foreign body is possible and given wound care instructions that include watching for signs of infection.
Tetanus vaccination and immune globulin may be needed depending on the wound type and patient's vaccination history (see table Tetanus Prophylaxis in Routine Wound Management).
Positioning for Wound Care
Position the patient comfortably; for an extremity wound, allow space for a basin to be placed under the wound during irrigation if possible.
Adjust the stretcher height so that you will be comfortable either sitting or standing at the bedside.
Adequate lighting, preferably with an overhead procedure light, should be used to allow visualization of the wound.
Step-by-Step Description of Wound Care
(For detailed discussions of the treatment and healing of skin wounds, see Lacerations.)
Preliminary tasks
Place all equipment on a tray within your reach.
Cleanse hands then don appropriate personal protective equipment.
Perform an initial cleansing of heavily contaminated wounds, eg, using tap water and a gentle hand soap. Depending on wound location, patients may be able to do this themselves; local anesthesia may be needed.
Hemostasis: Direct pressure to the site is the primary technique. Use finger pressure or gauze pads (may be moistened with sterile saline) to hold external pressure on the wound. Elevate the area if possible, and, if needed, use other means (eg, inflated blood pressure cuff, brief application of a proximal tourniquet, injected or topical 1% epinephrine with lidocaine) to attain hemostasis. Elevation and use of a proximally placed compression tourniquet are often helpful in achieving hemostasis of hand wounds. Hemostasis: Direct pressure to the site is the primary technique. Use finger pressure or gauze pads (may be moistened with sterile saline) to hold external pressure on the wound. Elevate the area if possible, and, if needed, use other means (eg, inflated blood pressure cuff, brief application of a proximal tourniquet, injected or topical 1% epinephrine with lidocaine) to attain hemostasis. Elevation and use of a proximally placed compression tourniquet are often helpful in achieving hemostasis of hand wounds.Avoid clamping blood vessels to avoid inadvertently clamping tendons, nerves, or other important structures.
Wound evaluation and neurovascular evaluation: Document the history of how the wound occurred and examination findings of wound location, size, degree of contamination, foreign bodies, associated injuries (eg, fractures and muscle and tendon disruptions), and neurovascular status distal to the wound. Check range of motion in all appropriate joints, particularly if a tendon injury is possible.
Imaging studies: Consider obtaining imaging studies for wounds involving glass or other foreign bodies when the base of the wound cannot be adequately evaluated (8) and if the history or clinical findings suggest a foreign body (eg, puncture wounds of the foot, any puncture deeper than 5 mm, or animal or human bites). Glass and most inorganic material (eg, stones) are usually detectable on radiographs (9). CT or MRI are more sensitive than plain radiography at detecting organic materials (eg, wood) and plastic. Ultrasound can also be used to detect retained foreign bodies (10).
Skin cleansing: Proceed from the wound edges outward, wiping in concentric circles with chlorhexidine or povidone-iodine solution followed by alcohol solution. Skin cleansing: Proceed from the wound edges outward, wiping in concentric circles with chlorhexidine or povidone-iodine solution followed by alcohol solution.Do not introduce a cleansing agent directly into the wound because many are toxic to tissues and may interfere with wound healing.
Local infiltration anesthesia
Local anesthetic (eg, 1% lidocaine or 1% lidocaine with epinephrine 1:100,000, 25-gauge needle) is used. Intradermal anesthetic injection itself is painful. Subdermal (subcutaneous) injection causes less pain and is preferred. For certain patients (eg, children), topical anesthetic (eg, proprietary emulsions of 2.5% lidocaine plus 2.5% prilocaine) is given prior to injection of local anesthetic. Local anesthetics are discussed in Local anesthetic (eg, 1% lidocaine or 1% lidocaine with epinephrine 1:100,000, 25-gauge needle) is used. Intradermal anesthetic injection itself is painful. Subdermal (subcutaneous) injection causes less pain and is preferred. For certain patients (eg, children), topical anesthetic (eg, proprietary emulsions of 2.5% lidocaine plus 2.5% prilocaine) is given prior to injection of local anesthetic. Local anesthetics are discussed inLacerations.
Hold the local anesthetic syringe at a shallow angle to the skin. Insert the needle directly into the exposed subdermal layer of the wound edge (ie, do not insert the needle percutaneously through intact skin) and advance the needle to reach the area to be anesthetized. Each time the needle is inserted or advance, pull back on the plunger to exclude intravascular placement; if blood is seen in the syringe, remove the needle and insert in a different location. Then inject the anesthetic, minimizing the pressure of injection while slowly withdrawing the needle.
Continue to anesthetize the circumference of the wound, subdermally inserting the needle into regions already anesthetized, advancing the needle into contiguous unanesthetized tissue, and injecting while withdrawing the needle. Repeat around the entire wound.
Nerve blocks and procedural sedation and analgesia should be used as needed for wounds that are difficult to anesthetize using local anesthesia (eg, very painful or large wounds) and for agitated or uncooperative patients. Very large or complicated wounds may need to be repaired in the operating room under general anesthesia if wound exploration, cleansing, debridement, and repair are likely to be too painful.
Wound cleansing
Dirty wounds may require scrubbing (as described below) before irrigation.
Irrigation
Irrigate the laceration using sterile saline or tap water in a 35- or 60-mL syringe (preferably with a splash guard attached but otherwise via a plastic catheter). Using tap water is not associated with an increased risk of infection (11).
Use a tissue forceps or probe to expose the tissue, and irrigate the entire depth and full extent of the wound.
During irrigation, press down on the plunger with the thumbs of both hands o produce enough pressure to remove particulate matter and bacteria. The volume of the fluid required varies with the size of the wound and the degree of contamination. Typically, 50 to 100 mL per centimeter of wound length is used, but for relatively clean wounds, 30 to 50 mL per centimeter is usually adequate (12, 13).
Continue irrigation until the wound is visibly clean. If irrigation is ineffective in removing visible particles, scrubbing (described below) is required.
Scrubbing
Scrub gently, using a fine-pore sponge (if available) to minimize tissue abrasion.
Use a portion of the sponge to first scrub the skin surface around the wound to remove foreign material that could enter the wound.
Use the remaining unused portion of the sponge to scrub the internal surface of the wound. Use care when scrubbing because the sponge may damage the internal tissues and provoke inflammation.
After scrubbing, irrigate the wound as described above.
Wound exploration
Place a fenestrated drape over the wound.
Examine the wound under adequate lighting and after bleeding has been controlled and at least initial cleansing has been performed.
Use a tissue forceps or probe to expose the wound tissue, and explore the entire depth and full extent of the wound to locate foreign bodies, particulate matter, bone fragments, and injuries to underlying structures. Do not explore the wound with your finger, because sharp foreign bodies may cause injury.
Use the forceps or #15 scalpel to remove visible objects from the wound. Use gauze to remove particulate matter.
Sometimes you may need to extend the wound edges or occasionally its depth to see adequately.
After inspecting and removing matter from the wound, irrigate the wound.
Wound debridement
Wound debridement techniques include: sharp debridement, high-pressure irrigation, or enzymatic debridement (application of topical agents that break down necrotic tissue).
Debride all devitalized and necrotic tissue: For sharp debridement, stabilize the wound edge with forceps, then excise the devitalized tissue with a scalpel or iris scissors. Make the incisions perpendicular to the skin surface, not on an angle (to maximize dermal apposition during closure).
Wound edge contamination that cannot be removed by irrigation and scrubbing (eg, grease and grit from power tool injury) may need to be removed by debridement.
To debride a fistula or through-and-through puncture wound, moisten some gauze and gently pull it through the tract in the direction opposite to the puncture using a forceps or hemostat.
After debridement, irrigate the wound again to remove any remaining debris.
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Wound closure
The wound is now prepared for closure (for information on which wounds may benefit from delayed closure or no closure, see Lacerations.) For wounds that require closure, the closure can be performed using simple interrupted sutures, buried deep dermal sutures, horizontal mattress sutures, vertical mattress sutures, a subcuticular running suture, adhesive, or stapling, depending on the nature of the wound.
Wound dressing
Dressings should keep wounds moist (6, 14). Typically, a nonstick porous dressing is placed directly over the wound, followed sometimes by an absorbent dressing sufficient to absorb the wound's secretions, followed lastly by an occlusive dressing. The dressing contacting the wound must not dry and adhere to the wound because fragile granulation tissue would be inadvertently debrided from the healing wound bed when the dressing is removed for changing. A dressing that is adherent to the wound can be soaked with water or saline for several minutes and then removed with gentle traction; this will minimize the removal of granulation tissue with the dressing.
Gently wipe away any remaining cleansing agent and dried blood or skin debris using moistened gauze.
If the wound has been closed with sutures, many operators apply topical antibiotic to keep the sutures from adhering to the dressing.
Place a nonadherent dressing on the wound.
If significant oozing or bleeding seems possible, apply a sterile absorbent dressing over the nonadherent dressing. Use a thick layer if considerable drainage is anticipated. Follow wounds at risk of heavy bleeding closely.
For wounds in locations subject to significant contamination, apply a sterile occlusive dressing.
Apply adhesive tape or a circumferential gauze wrap to keep the dressing in place. Be careful not to place circumferential wraps too tightly, which may lead to excessive compression and subsequent ischemia.
Some wounds typically are not dressed (eg, scalp wounds where hair may prevent dressings from adhering).
Aftercare for Dressing Wounds
Instruct the patient to keep the dressing dry and in place and to return in 2 days for a wound check or, if the wound is left open and delayed closure is anticipated, in 3 to 5 days.
Although there are not specific guidelines, prophylactic oral antibiotics may be given to prevent infection of dirty (especially organically contaminated) wounds, particularly for diabetic and immunocompromised patients.
Warnings and Common Errors for Wound Care
Proper wound care must include thorough examination regardless of anticipated closure method; a common error is to do cursory exploration and no debridement because a noninvasive closure not requiring local anesthesia is planned.
Wounds with possible retained foreign bodies, joint penetration, or damage to underlying structures such as tendons require full wound exploration and observation through the range of motion of adjoining joints.
Drugs Mentioned In This Article
