Principles of Wound Management

Indiana University Department of Emergency Medicine

Nurse Practitioner Lecture Series

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.

Hair and Eyebrows

• Don’t 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

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.

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

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

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

Healing by Primary Intention

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

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

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

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