Principles of Wound Management

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Principles of Wound Management

• Indiana University Department of Emergency
  Medicine
• Nurse Practitioner Lecture Series

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Skin Preparation

• Used to decrease bacterial counts surrounding
  wounds
• Povidine-Iodine solution (Betadine) and
  Chlorhexidine (Hibiclens) solutions are
  available
• can be used to cleanse surrounding skin surfaces
  but may inhibit the immune response when placed
  within wounds.

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Hair and Eyebrows

• Dont shave, this increases infection 10x
  secondary to abrasions produced by razor
• Potential that the eyebrow may not grow back
• Clipping of hair or applying lubricant jelly are
  good alternatives

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Wound Irrigation

• Most important determinant in decreasing risk of
  infection
• Goal is decreasing bacterial load within wounds
• High-pressure irrigation
• Technique seems to be more important than type of
  irrigation solution used
• Approx. 7 psi needed to significantly decrease
  bacterial load and rate of infection
• Accomplished with a 18g angiocath with large
  syringe.

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Wound Irrigation

• Low pressure irrigation is not as effective as
  high pressure irrigation
• Pouring
• Soaking
• Gravity wash
• Poke a hole in the top of a bottle
• Bulb syringe
• All do not create enough pressure

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Wound Irrigation

• Normal saline shown to be as effective (and more
  cost effective) than other commercial solutions
• Do Not use betadine, hydrogen peroxide, or
  isopropyl alcohol
• Tissue toxicity
• The KEY is copious use of wound irrigation
• General rule is at least 50 cc of irrigation
  applied with at least 7psi of pressure per cm of
  wound

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Wound Closure

• Three options
• Healing by primary intention
• Healing by secondary intention
• Delayed primary closure
• Choice is based on risk for infection, location
  and inherent wound characteristics

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Healing by Primary Intention

• Also called primary closure
• Most common method used
• Wound bandaged, glued, stapled or sutured

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Healing by Secondary Intention

• Wound is left open and allowed to granulate from
  within
• Grossly contaminated and other high risk wounds
  can be handled this way
• Often results in less desirable functional and
  cosmetic outcome

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Delayed Primary Closure

• Useful for wounds which are high risk for
  infection, but where the cosmetic outcome of
  secondary intention would be undesirable
• Wounds are left open, packed, and covered with a
  dressing
• 3-5 days later the wound is debrided and closed

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Method of Closure

• Goal of primary closure is to approximate the
  wound edges with the best cosmetic outcome
• Scaring is the result of tension on wound edges
  and wound contraction with healing
• Gaping wounds tend to scar more because of
  increased tension on the wound
• Everting wound edges results in a better outcome
  because it allows for wound contraction

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