Lacerations, contusions, abrasions, and other common soft-tissue injuries rank as the third most frequent problems encountered by the primary care physician. Understanding wound biology and treatment can enable the primary care physician to determine the most effective procedures for treating such injuries.
Priorities for Wound Care
Sterility is not the objective; healthy skin lives in relative harmony with bacteria. Injury, how-ever, changes the equilibrium dramatically and increases bacterial levels tenfold or more. Optimal wound care involves all of the following, in chronological order:
- Inspection: to determine the magni-tude of the injury and whether bleeding is controlled.
- Reassurance, Sedation, Analgesia: to calm and reassure patient and family and increase patient comfort.
- Anesthesia: preceding manipulation of the wound.
- Preparation, Irrigation and Debridement: use a balanced salt solution to dislodge dirt and facilitate identification of devitalized tissue for debridement.
- Wound Closure Determination: when significant time (more than 24 hours) has passed since the injury, or if injury is heavily contaminated, closure may be delayed three to five days (except for facial wounds).
- Suture Closure: using appropriate suture and needle type, and stitch type.
- Dressings: to enhance wound healing environment.
- Tetanus Prophylaxis Evaluation: differentiating between tetanus booster and full three-injection prophylaxis.
- Antibiotics: for seriously contaminated wounds, all animal and human btes, and delayed treatment.
- Instructions to Patients: speak slowly and use easy-to-understand language. Write down all essential post-treatment instructions.
- Follow-Up: Re-evaluate injury after 24-48 hours with repeat visits according to type of wound and patient compliance.
Lidocaine with epinephrine is the most frequently used anesthetic. It should be injected very slowly, directly into the wound, and closely watched for signs of toxicity. Note: Epinephrine should never be used for anesthesia of the fingers.
Primary Areas of Bleeding
- Subdermal Plexus: a rich network of vessels at the junction of the dermis and subcutaneous fat
- Superficial Veins: usually lying superficial to the arterial network
- Superficial Arterial Branches: most commonly found in the face and scalp
How to Prevent Bleeding
- Take a bleeding history.
- Take advantage of posture to avoid high venous pressure at the incision site.
- Check the patient's anatomy for superficial veins or palpable arteries.
- Use dilute epinephrine to limit dermal bleeding.
How to Stop Bleeding
- Cut through the entire dermis to allow retraction of dermis.
- Make sure you can see what you are clamping.
- Use an assistant.
- Use suture ligatures for securing major blood vessels.
- Summon assistance from a plastic surgeon in critical situations.
Adhesive strips may provide an alternative to sutures and can be helpful as suture reinforcement. Always use with an adequate dressing.
Sutures can be absorbable or non-absorbable, and vary in size and strength. Needles should have a cutting tip for skin, dermis and musculofascial repair.
Types of Stitches
- Simple Interrupted Everting Stitch
- Most widely used stitch
- Mattress Suture
- May strangulate tissue and lead to ischemia
- Continuous Stitch
- For scalp injuries
- Continuous Buried Pullout Stitch
- Very useful for linear wounds
Arrange damaged but viable tissue and join key landmarks first. Make only as many stitches as it takes to do the job. Do not tie too tightly. Use buried stitches only when needed. Remove stitches and reopen wound if signs of infection develop.
Special suturing situations can occur with lip wounds, ear lacerations, eyebrows, the nostril base, eyelid lacerations, tongue and leg wounds.
Functions of a Dressing
- Protect from further trauma
- Provide a suitable environment for optimum healing
- Absorb exudate from the wound surface
- Exert reasonable compression to limit wound edema
- Immobilize and rest the wound
Characteristics of a Good Dressing
- Layer One: lubricated gauze
- Layer Two: fluffed gauze for absorption
- Layer Three: non-elastic roll gauze for controlled compression
The Open Wound
Dressing changes should involve only the absorptive layers and not dislodge initial layer. Wet-to-damp dressings maintain a moist environment for healing.
A minor burn is small, of partial thickness, and does not involve the face, hands, feet or genitalia. However, even a partial-thickness burn should be closely monitored, as its depth can be easily misjudged.
Gently cleanse and apply lubricated gauze and absorbent dressing, changing after 24 to 48 hours. Re-examine frequently, as necessary.
Animal and Human Bites
Consider every bite to be contaminated. The wound may require a delayed closure. Use antibiotics, and perform extra irrigation and debridement. Immobilize the wound as much as possible. Schedule frequent follow-up visits.
Types of injury include:
- Partial and complete tip loss
- Nail bed injuries
- Fingertip infections
When less than 50% of the fingertip is missing, healing by epithelial migration and contraction may be sufficient. For more than 50% loss, tissue replacement is usually required. Nail bed injuries require releasing pressure from the subungual hematoma. Fingertip infections often require antibiotics, rest, elevation and, in some cases, surgical drainage.
Scars are inevitable following any interruption of human skin integrity. Scars are permanent, though they become less conspicuous with time. Scar revision may change the direction of the scar and make it less noticeable.
Referring for Plastic Surgery
Referral to a plastic surgeon should be considered when any of the following occur:
- The patient asks for a plastic surgeon.
- The patient is angry or questions your qualifications.
- There is a high likelihood of complications.
- The patient has multiple tissue injuries.