Traumatic Wounds: Cleansing and Dressing | Practice | Nursing Times

7/31/2019 Traumatic Wounds: Cleansing and Dressing | Practice | Nursing Times

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Traumatic wounds: cleansing and dressing

VOL: 97, ISSUE: 28, PAGE NO: 50

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 tis-

sue viability nurse; Martina Dunlop, BSc, RGN, is an emergency nurse practition-er; 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.

Infection and poor cosmetic outcomes are just two of the adverse effects that can oc-cur 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 as-

sessment and wound management skills. Wound cleansing and debridement

The most important factor in the management of traumatic wounds is meticulous irri-

gation 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 pa-

tient 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 anaesthe-

sia, 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 de-lay 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 indi-


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vidual. Where sharp debridement is not appropriate, various topical applications can

be effective, including hypochlorites, enzymatic agents, hydrogels, alginates and hy-

drocolloids. - Practice point 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). Irrigation

In the first instance, the injured area should be irrigated with copious amounts of wa-

ter or saline, preferably warmed to 37[s7]C. However, the amount of pressure re-quired 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 effi-

cacy of high-pressure irrigation (50psi), using a pulsatile jet, has also been tested. Al-

though this method significantly reduced bacterial counts in devitalised, contaminat-

ed wounds, Brown et al (1978) found that, overall, the percentage of gross infection

was higher in wounds treated by high-pressure irrigation. Another potential compli-

cation 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. Thiscan 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. - Practice point Degreasing agents such as Swarfega

can help to remove oil from the skin. This must be applied before the wound is irri-

gated with fluid. Asepsis is required only once all gross contaminants have been re-

moved from the wound bed. Antiseptics

There is some debate about the use of topical antiseptic solutions that arises from re-search 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 bacteri-

cidal 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 ex-

ample, soapy solutions such as chlorhexidine may be useful in removing congealedblood 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


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aware of the indications and contraindications of each antiseptic, enabling them to

make an informed choice. Wound closure

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 adead 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 devi-

talised 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 ny-

lon 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 disrup-

tion and foreign body reaction. Staples are particularly useful for closing scalpwounds. Local anesthesia is not usually required. - Practice point In certain situa-

tions, 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. Re-

verse-cutting needles are used to suture skin because they penetrate with ease. Skin

tapesPaper 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 be-

come wet. - Practice point Application of friars balsam at the wound margin may

help skin tapes adhere to the skin. Tissue glue

Tissue glue is painless to apply and sets quickly once it makes contact with tissue flu-

id, it is useful for small cuts and lacerations, especially in children. It cannot be used


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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. Wound dress-

ings

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, hydro-

colloids and hydropolymer foams, meet these requirements, whereas tulles and cot-ton/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 ad-

verse 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 recom-

mended 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 throm-

bolytic agent (Bux et al, 1997). Hydrogels actively rehydrate devitalised tissue by do-

nating water to the desiccated matter. This creates a moist environment that facili-

tates autolysis, but the efficacy of hydrogels is reduced in the presence of excess exu-date. 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 indiscriminate-

ly 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 exu-date levels; - Allow gaseous exchange; - Provide a constant wound interface tempera-

ture; - Protect the wound from pathogens, trauma and particulate matter.

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Traumatic Wounds: Cleansing and Dressing | Practice | Nursing Times