Christine Dearden is A&E consultant; Janice Donnell, RGN, RSCN, is a staff nurse; Jean Donnelly, BSc, RGN, PGDip. wound healing and tissue repair, is tissue viability nurse; Martina Dunlop, BSc, RGN, is an emergency nurse practitioner; Royal Hospitals and Dental Hospital Health and Social Services Trust, Belfast.
Infection and poor cosmetic outcomes are just two of the adverse effects that can occur as a result of the mismanagement of a traumatic injury to the skin. It is, therefore, vital that nurses involved in the care of patients with such injuries have excellent assessment and wound management skills.
Wound cleansing and debridement
The most important factor in the management of traumatic wounds is meticulous irrigation and debridement. Dead tissue, foreign debris, devitalised skin and haematoma must be removed to reduce the number of contaminating bacteria and deprive those that remain of their breeding environment. This helps to protect the patient from the spread of infection, including tetanus, and ensures that the remaining tissue is viable, with a good blood supply that should heal with minimal scarring.
In superficial wounds, cleansing and debridement can be achieved through thorough irrigation and, if necessary, scrubbing or dermabrasion of the injured parts with a soft nailbrush, toothbrush or sponge. Scrubbing will cause increased tissue oedema and a decrease in host defences (Maklebust, 1996) but may be necessary to prevent tatooing with contaminants. It will be painful and requires adequate analgesia.
Local anaesthesia, such as 1% lignocaine, may be useful (Heyworth, 1997), but Edlich et al (1988) highlight the importance of balancing the pain caused by dermabrasion against that experienced when the needle passes through the skin. Topical anaesthesia, such as 2% lignocaine, may also be of benefit, but there is a lack of research on its use in wounds. It is not licensed for this purpose, so it needs to be prescribed (Bianchi, 2000). General anaesthesia may be required in the case of deep wounds as the entire tract will need surgical exploration, cleansing and debridement to identify damage to deep structures.
Devitalised tissue in the wound bed will significantly delay healing and, in some cases, prevent it. Sharp debridement is the quickest method to remove it, but this should be carried out only by an experienced and skilled individual. Where sharp debridement is not appropriate, various topical applications can be effective, including hypochlorites, enzymatic agents, hydrogels, alginates and hydrocolloids. Antibiotic therapy cannot replace thorough cleansing and adequate debridement. Trauma caused by scrubbing or dermabrasion may be minimised through the use of a fine-pore sponge (Rodeheaver et al, 1975).
In the first instance, the injured area should be irrigated with copious amounts of water or saline, preferably warmed to 37[s7]C. However, the amount of pressure required to thoroughly irrigate a wound is open to debate. If it is too low, debris may remain; if it is too high, it may traumatise healthy tissue or drive bacteria further into the wound.
Recommended irrigation pressures range from four to 15lb per square inch (Rodeheaver et al, 1975; Heyworth, 1997). This can be approximated by using a 35ml syringe and a 19-gauge needle. However, needlestick injury to either the patient or the nurse is a hazard. The use of a plastic catheter can eliminate this risk. The efficacy of high-pressure irrigation (50psi), using a pulsatile jet, has also been tested. Although this method significantly reduced bacterial counts in devitalised, contaminated wounds, Brown et al (1978) found that, overall, the percentage of gross infection was higher in wounds treated by high-pressure irrigation.
Another potential complication of high-pressure irrigation is exposure to cross-infection owing to splashback of irrigants. This can be reduced by cupping a gloved hand around the wound (Chrisholm et al, 1992) or using cup-like devices designed to prevent splatter. A study by Angeras et al (1992) found a lower incidence of infection in traumatic wounds that had been cleansed with tap water than those cleansed with saline. This can probably be explained through the earlier work of Rodeheaver et al (1975), which showed that the force of the pressure used to cleanse the wound was more important than the type of solution used.
Degreasing agents such as Swarfega can help to remove oil from the skin. This must be applied before the wound is irrigated with fluid. Asepsis is required only once all gross contaminants have been removed from the wound bed.
There is some debate about the use of topical antiseptic solutions that arises from research showing they are an ineffective cleansing agent, have toxic effects on tissues and delay wound healing (Brennan and Leaper, 1985). However, others believe they may still have a role to play in traumatic wound management owing to their bactericidal properties (Thomas, 1990).
Research on the effect of antiseptics on traumatic wounds is not sufficient to direct practice, so we suggest that all topical antiseptics should be used with caution. While it is clear that antiseptics should not be used as a routine cleansing agent, certain solutions may be useful in one-off situations. For example, soapy solutions such as chlorhexidine may be useful in removing congealed blood and dirt from hair, and hydrogen peroxide can be used to lift dirt and gravel from the wound surface. Practitioners must be accountable for their actions and aware of the indications and contraindications of each antiseptic, enabling them to make an informed choice.
If the wound is clean, it may be closed primarily using sutures, staples, skin tapes or adhesives (glues). Good tissue approximation with minimal tension is fundamental to healing.
In deep wounds, it is important to ensure that the edges are approximated in the depths of the wound as well as on the surface of the skin. This may involve closing the wound with deep sutures as well as closing the skin. If this is not done a ‘dead space’ may be left within the wound, providing a focus for the formation of haematomas and infection.
Primary closure is not an option if contaminants or devitalised tissue cannot be removed from the wound, it is infected or it is an old injury. In such cases, alternative options include delayed primary closure or not to close the wound at all but letting it heal by granulation (Table 1).
Sutures and staples
Properly applied sutures promote wound healing and reduce the risk of sepsis by eliminating wound cavitations and realigning tissue planes and opposing wound edges. The choice of suture material depends on the depth of the wound and type of tissue.
Absorbable sutures are used to approximate the deeper layers of the skin. Non-absorbable sutures are used for skin closure. Monofilament sutures such as nylon are inert and gentle on the tissue. There is no indication for the use of catgut or silk in wound management. The smallest size suture material practical for the wound should be used. Fine sutures such as 5/0 or 6/0 are used to close wounds on the face and neck (Table 2). An inappropriately thick suture will result in more tissue disruption and foreign body reaction.
Staples are particularly useful for closing scalp wounds. Local anesthesia is not usually required. In certain situations, for example with wounds to the face, medical staff may decide to suture up to within 12 hours of injury (it is important to follow local protocols) to limit scarring in a cosmetically important area. Round-body needles cause minimal trauma but do not penetrate the skin well and are therefore used for the closure of subcutaneous fat. Reverse-cutting needles are used to suture skin because they penetrate with ease.
Paper adhesive strips, such as Steristrips, are useful for superficial lacerations that will not be under a great amount of tension or flexion: they are contraindicated in wounds overlying or near joints, especially extensor surfaces. The main benefits of skin tapes over sutures are that they are quick and fairly painless to apply, are less likely to cause tissue ischaemia and are associated with a lower rate of infection. The main disadvantage of skin adhesives is that they may peel off, especially if they become wet. Application of friar’s balsam at the wound margin may help skin tapes adhere to the skin.
Tissue glue is painless to apply and sets quickly once it makes contact with tissue fluid, it is useful for small cuts and lacerations, especially in children. It cannot be used on lacerations greater than 3cm long, those near the eye or mouth, deep lacerations or ragged lacerations. It is used solely to weld the surface of the wound.
In the past, wound contact materials were used simply to absorb blood and exudate. Today, they are also used to protect the injured/healing tissue and create optimal conditions for healing. Many modern dressings, such as alginates, hydrogels, hydrocolloids and hydropolymer foams, meet these requirements, whereas tulles and cotton/gauze pads do not.
The type of product that is chosen usually depends on the depth of tissue damage, the type of tissue in the wound bed and the level of exudate. Hypochlorite solutions such as Eusol are non-selective and will remove viable as well as non-viable tissue (Brennan and Leaper, 1985). Despite this and the prestated adverse effects, some plastic surgeons find hypochlorites useful in the preparation of an area for grafting. However, as its disadvantages outweigh its benefits it is not recommended in A&E.
Enzymatic products such as streptokinase/streptodornase liquefy slough. However, the topical application of streptokinase has been shown to result in a significant production of antistreptokinase antibody. Topical streptokinase should be avoided in patients at risk of coronary artery thrombosis. If a thrombolytic agent is required within six months of administering topical streptokinase/streptodornase, then intravenous streptokinase should be withheld in favour of an alternative thrombolytic agent (Bux et al, 1997).
Hydrogels actively rehydrate devitalised tissue by donating water to the desiccated matter. This creates a moist environment that facilitates autolysis, but the efficacy of hydrogels is reduced in the presence of excess exudate. Where this is the case, it is better to use a product such as an alginate to absorb the exudate and produce a gel.
Hydrocolloids are useful for wounds that produce a low to moderate amount of exudate. Antimicrobial dressings may be of some benefit in reducing bacterial colonisation. They should not, however, be used indiscriminately as misuse can lead to sensitisation and bacterial resistance.
Ultimately, the choice of dressing should meet the requirements for optimal wound healing (Thomas, 1990; Morrison, 1992), which are to:
- Create a moist wound environment;
- Control exudate levels;
- Allow gaseous exchange;
- Provide a constant wound interface temperature;
- Protect the wound from pathogens, trauma and particulate matter.