The basic principles for the management of a wound or laceration are:
- Cleaning the Wound
- Skin closure
- Dressing and follow-up advice.
These principles can be applied to any simple wound, yet always involve your senior colleagues for advice and input as necessary.
Haemostasis is the process that causes bleeding to stop. In most wounds, haemostasis will be spontaneous. In cases of significant injury or laceration of vessels, steps may need to be taken to reduce bleeding and aid haemostasis. These include pressure, elevation, tourniquet, and suturing.
Cleaning the Wound
Wound cleaning is important for reducing infection and promoting healing. There are five aspects of wound cleaning:
- Disinfect the skin around the wound with antiseptic
- Avoid getting alcohol or detergents inside the wound.
- Decontaminate the wound by manually removing any foreign bodies.
- Debride any devitalised tissue where possible.
- Irrigate the wound with normal saline
- If there is no obvious contamination present, low pressure irrigation is sufficient (pouring normal saline from a sterile container carefully into the wound)
- If the wound is clearly contaminated, it must be irrigated at high pressure (via a green needle and syringe) to remove any visible debris present.
- Antibiotics are advised in high-risk wounds or signs of infection (follow local antibiotic guidelines)
- Risk factors for wound infection include foreign body present or heavily soiled wounds, bites (including human), puncture wounds and open fractures.
Analgesia will allow for a humane and easier closure of the wound. Infiltration with a local anaesthetic is the most common form of analgesia used, with regular systemic analgesia (paracetamol/ibuprofen) used as an adjunct.
The maximum level of lidocaine is 3mg/kg (the addition of adrenaline allows for 6mg/kg). A 1% solution of lidocaine typically equates to 10mg/ml. Remember do not use adrenaline with local anaesthetic if administering in or near appendages (e.g. a finger)
The aid wound healing, the edges of the wound can be manually opposed. There are four main methods of doing so; skin adhesive strips, tissue adhesive glue, staples, and sutures:
- Skin adhesive strips (e.g. Steri-StripsTM) are suitable if no risk factors for infection are present
- Tissue adhesive glue (e.g. Indermil®) can be used for small lacerations with easily opposable edges; a popular choice in paediatrics
- Sutures are typically used for any laceration greater than 5cm, deep dermal wounds, or in locations that are prone to flexion, tension, or wetting
- Staples can be used for some scalp wounds.
Dressing the Wound and Follow-Up
Correct dressing of the wound will reduce infection and contamination. When applying a wound dressing to a non-infected laceration, the first layer should be non-adherent (such as a saline-soaked gauze), followed by an absorbent material to attract any wound exudate, and finally soft gauze tape to secure the dressing in place.
Tetanus prophylaxis is required for any individual not up to date with (or unsure of) their tetanus immunisation status. A fully immunized person will have had a primary course of three vaccines followed by two boosters spaced 10 years apart. In a wound that is unlikely to become infected tetanus prophylaxis is not required.
Following initial wound management, advise patients to:
- Seek medical attention for any signs of infection (increasing pain, tenderness, redness, or swelling) or general malaise and fever.
- Take simple analgesia (e.g. paracetamol or ibuprofen).
- Keep the wound dry as much as possible, even if wearing a waterproof dressing.
Any sutures or adhesive strips should be removed 10-14 days after initial would closure (or 3-5 days if on the head); tissue adhesive glue will naturally slough off after 1-2 weeks. Remove dressings at the same time as the sutures or adhesive strips.