Wound care

Definition

A wound is a disruption in the continuity of cells—anything that causes cells that would normally be connected to become separated. Wound healing is the restoration of that continuity. Several effects may result with the occurrence of a wound: immediate loss of all or part of organ functioning, sympathetic stress response, hemorrhage and blood clotting, bacterial contamination, and death of cells. The most important factor in minimizing these effects and promoting successful care is careful asepsis, which can be accomplished using aseptic techniques when treating a wound.

Description

Wound healing is a biological process that begins with trauma and ends with scar formation. There are two types of tissue injury: full and partial thickness. Partial thickness injury is limited to the epidermis and superficial dermis, with no damage to the dermal blood vessels. Healing occurs by regeneration of other tissues. Full thickness injury involves loss of the dermis extends to deeper tissue layers, and disrupts dermal blood vessels. Wound healing involves the synthesis of several types of tissue and scar formation.

The three phases of repair are lag, proliferative, and remodeling. Directly after injury, hemostasis is achieved with clot formation. The fibrin clot acts like a highway for the migration of cells into the wound site. Within the first four hours of injury, neutrophils begin to appear. These inflammatory cells kill microbes, and prevent the colonization of the wound. Next the monocyte, or macrophage, appears. Functions of these cells include the killing of microbes, the breakdown of wound debris, and the secretion of cytokines that initiate the proliferative phase of repair. Synthetic cells, or fibroblasts, proliferate and synthesize new connective tissue, replacing the transitional fibrin matrix. At this time, an efficient nutrient supply develops through the arborization (terminal branching) of adjacent blood vessels. This ingrowth of new blood vessels is called angiogenesis. This new and very vascular connective tissue is referred to as granulation tissue.

The first phase of repair is called the lag or inflammatory phase. The inflammatory response is dependent on the depth and volume of tissue loss from the injury. Characteristics of the lag phase include acute inflammation and the initial appearance and infiltration of neutrophils. Neutrophils protect the host from microorganisms and infection. If inflammation is delayed or stopped, the wound becomes susceptible to infection and closure is delayed.

The proliferative phase is the second phase of repair and is anabolic in nature. The lag and remodeling phase are both catabolic processes. The proliferative phase generates granulation tissue. In this process, acute inflammation releases cytokines, promoting fibroblast infiltration of the wound site, then creating a high density of cells. Collagen is the major connective tissue protein produced and released by fibroblasts. The connective tissue physically supports the new blood vessels that form and endothelial cells promote ingrowth of new vessels. These new blood vessels are necessary to meet the nutritional needs of the wound healing process. The mark of wound closure is when a new epidermal cover seals the defect. The process of wound healing continues beneath the new surface. This is the remodeling or maturation phase and is the third phase in healing.

The first principle of wound care is the removal of nonviable tissue, including necrotic (dead) tissue, slough, foreign debris, and residual material from dressings. Removal of nonviable tissue is referred to as debridement ; removal of foreign matter is referred to as cleansing. Chronic wounds are colonized with bacteria, but not necessarily infected. A wound is colonized when a limited number of bacteria are present in the wound and are of no consequence in the healing process. A wound is infected when the bacterial burden overwhelms the immune response of the host and bacteria grow unchecked. Clinical signs of infection are redness of the skin around the wound, purulent (pus-containing) drainage, foul odor, and edema.

The second principle of wound care is to provide a moist environment. This has been shown to promote reepithelialization and healing. Exposing wounds to air dries the surface and may impede the healing process. Gauze dressings provide a moist environment provided they are kept moist in the wound. These are referred to as wet-to-dry dressings. Generally, a saline-soaked gauze dressing is loosely placed into the wound and covered with a dry gauze dressing to prevent drying and contamination. It also supports autolytic debridement (the body's own capacity to lyse and dissolve necrotic tissue), absorbs exudate, and traps bacteria in the gauze, which are removed when the dressing is changed.

Preventing further injury is the third principle of wound care. This involves elimination or reduction of the condition that allowed the wound to develop. Factors that contribute to the development of chronic wounds include losses in mobility, mental status changes, deficits of sensation, and circulatory deficits. Patients must be properly positioned to eliminate continued pressure to the chronic wound. Pressure reducing devices, such as mattresses, cushions, supportive boots, foam wedges, and fitted shoes can be used to keep pressure off wounds.

Providing nutrition, specifically protein for healing, is the fourth principle of healing. Protein is essential for wound repair and regeneration. Without essential amino acids, angiogenesis, fibroblast proliferation, collagen synthesis, and scar remodeling will not occur. Amino acids also support the immune response. Adequate amounts of carbohydrates and fats are needed to prevent the amino acids from being oxidized for caloric needs. Glucose is also needed to meet the energy requirements of the cells involved in wound repair. Albumin is the most important indicator of malnutrition because it is sacrificed to provide essential amino acids if there is inadequate protein intake.

Diagnosis/Preparation

Effective wound care begins with an assessment of the entire patient. This includes obtaining a complete health history and a physical assessment. Assessing the patient assists in identifying causes and contributing factors of the wound. When examining the wound, it is important to document its size, location, appearance, and the surrounding skin. The health care professional also examines the wound for exudate, necrotic tissue, signs of infection, and drainage, and documents how long the patient has had the wound. It is also important to know what treatment, if any, the patient has previously received for the wound.

Actual components of wound care include cleaning, dressing, determining frequency of dressing changes, and reevaluation. Dead tissue and debris can impede healing: the goal of cleaning the wound is its removal. When cleaning the wound, protective goggles should be worn and sterile saline solution should be used. Providone iodine, sodium hypochlorite, and hydrogen peroxide should never be used, as they are toxic to cells.

Gentle pressure should be used to clean the wound if there is no necrotic tissue. This can be accomplished by utilizing a 60 cc catheter tip syringe to apply the cleaning solution. If the wound has necrotic tissue, more pressure may be needed. Whirlpools can also be used for wounds having a thick layer of exudate. At times, chemical or surgical debridement may be needed to remove debris.

Dressings are applied to wounds for the following reasons: to provide the proper environment for healing, to absorb drainage, to immobilize the wound, to protect the wound and new tissue growth from mechanical injury and bacterial contamination, to promote hemostasis, and to provide mental and physical patient comfort. There are several types of dressings and most are designed to maintain a moist wound bed:

• Alginate: Made of non-woven fibers derived from seaweed, alginate forms a gel as it absorbs exudate. It is used for wounds with moderate-to-heavy exudate or drainage, and is changed every 12 hours to three days, depending on when the exudate penetrates the secondary dressing.
• Composite dressings: Combining physically distinct components into a single dressing, composite dressings provide bacterial protection, absorption, and adhesion. The frequency of dressing changes vary.
• Foam: Made from polyurethane, foam comes in various thicknesses having different absorption rates. It is used for wounds with moderate-to-heavy exudate or drainage. Dressing change is every three to seven days.
• Gauze: Available in a number of forms including sponges, pads, ropes, strips, and rolls, gauze can be impregnated with petroleum, antimicrobials, and saline. Frequent changes are needed because gauze has limited moisture retention and properties, and there is little protection from contamination. With removal of a dried dressing, there is a risk of wound damage to the healing skin surrounding the wound. Gauze dressings are changed two to three times a day.
• Hydrocolloid: Made of gelatin or pectin, hydrocolloid is available as a wafer, paste, or powder. While absorbing exudate, the dressing forms a gel. Hydrocolloid dressings are used for light-to-moderate exudate or drainage. This type of dressing is not used for wounds with exposed tendon or bone, third-degree burns, or in the presence of bacterial, fungal, or viral infection or active cellulitis or vasculitis because it is almost totally occlusive. Dressings are changed every three to seven days.
• Hydrogel: Composed primarily of water, hydrogel dressings are used for wounds with minimal exudate. Some are impregnated in gauze or non-woven sponge. Dressings are changed one or two times a day.
• Transparent film: An adhesive, waterproof membrane that keeps contaminants out while allowing oxygen and water vapor to cross through, it is used primarily for wounds with minimal exudate. It is also used as a secondary material to secure non-adhesive gauzes. Dressings are changed every three to five days if the film is used as a primary dressing.

In cases where a wound is particularly severe, large, or if it is a third degree burn, cellular wound healing products may be used to close the wound and speed recovery. In some cases (i.e., a third-degree burn), a skin graft will often be used. Although most surgeons prefer to use skin donated from another person (known as cadaver skin, or human allograft), skin donations are not always available. They must rely on more recent products available, such as cellular wound dressings, for the treatment of burns. For skin grafting of full-thickness burn wounds, surgeons use healthy skin from another part of the person's own body (autografting) as a permanent treatment. Surgeons may use cellular wound dressings as a temporary covering when the skin damage is so extensive that there is not enough healthy skin available to graft initially. This helps prevent infection and fluid loss until autografting can be performed.

The survival rate for burn patients has increased considerably through the process of quickly removing dead tissue and immediately covering the wound. Burns covering half the body were routinely fatal 20 years ago but today, even people with extensive and severe burns have a good chance of survival, according to the American Burn Association.

Cellular wound dressings

In recent years, the technology of burn and wound care using cellular wound dressings and grafts are helping to transform the treatment of burns and chronic wounds by decreasing the risk of infection, protecting against fluid loss, requiring fewer skin grafts, and promoting and speeding the healing process. These dressings provide a cover that keeps fluids from evaporating and prevents blood from oozing out once the dead skin has been removed. Some of these products grow in place and expand natural skin when it heals.

Cellular wound dressings may look and feel like skin, but they do not function totally like skin because they are missing hair follicles, sweat glands, melanocytes, and Langerhans' cells. Some cellular wound dressings have a synthetic top layer structured like an epidermis. It peels away over time, or is replaced with healthy skin through skin grafting. How these products are involved in wound repair is a subject of great scientific interest; it is known that they promote a higher rate of healing than does standard wound care.

People with severe wounds, chronic wounds, burns, and ulcers can benefit from cellular wound dressings. Several artificial skin products are available for nonhealing wounds or burns such as: Apligraft® (Norvartis), Demagraft®, Biobrane®, Transcyte® (Advance Tissue Science), Integra® Dermal Regeneration Template® (from Integra Life Sciences Technology), and OrCel®.

• Apligraf is a two-layer wound dressing that contains live human skin cells combined with cow collagen. It delivers live cells from a different donor (circumcised infant foreskin). Thousands of pieces of Apligraf are produced in the laboratory from one small patch of cells from a single donor.
• Dermagraft is made from human cells placed on a dissolvable mesh material. The mesh material is gradually absorbed and the human cells grow and replace the damaged skin after being placed on the wound or ulcer.
• Biobrane is used as a temporary dressing for a variety of wounds, including ulcers, lacerations, and full-thickness burns. It may also be used on wounds that develop on areas from which healthy skin is transplanted to cover damaged skin. It consists of an ultrathin silicone film and nylon fabric. As the wound heals, or until autografting becomes possible, the Biobrane is trimmed away.
• TransCyte is used as a temporary covering over full thickness and some partial thickness burns until autografting is possible, as well as a temporary covering for some burn wounds that heal without autografting. It consists of human cells from circumcised infant foreskin, and grown on nylon mesh, combined with a synthetic epidermal layer. TransCyte starts with living cells, but these cells die when it is shipped in a frozen state to burn treatment facilities. The product is then thawed and stretched over a burn site. In one to two weeks, the TransCyte starts peeling off, and the surgeon trims it away as it peels.
• Integra Dermal Regeneration Template is used to treat full thickness and some partial thickness burns. Integra consists of two layers; the bottom layer, made of shark cartilage and collagen from cow tendons, acts as a matrix onto which a person's own cells migrate over two to three weeks. A new dermis is created as the cells gradually absorb the cartilage and collagen. The top layer is a protective silicone sheet that is peeled off after several weeks, while the bottom layer is a permanent cover. A very thin layer of the person's own skin is then grafted onto the neo-dermis.
• OrCel is also made from circumcised infant foreskin, grown on a cow collagen matrix, and used to treat donor sites in burn patients. It is also used to help treat epidermolysis bullosa, a rare skin condition in children.

To ensure the safety and quality of products such as cellular wound dressings, the Food and Drug Administration (FDA) has initiated a new regulatory system.

Risks

• Hematoma: dressings should be inspected for hemorrhage at intervals during the first 24 hours after surgery. A large amount of bleeding is to be reported to a health care professional immediately. Concealed bleeding sometimes occurs in the wound, beneath the skin. If the clot formed is small, it will be absorbed by the body, but if large, the wound bulges and the clot must be removed for healing to continue.
• Infection: The second most frequent nosocomial (hospital-acquired) infection in hospitals is surgical wound infections with Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa. Prevention is accomplished with meticulous wound management. Cellulitis is a bacterial infection that spreads into tissue planes; systemic antibiotics are usually prescribed to treat it. If the infection is in an arm or leg, elevation of the limb reduces dependent edema and heat application promotes blood circulation. Abscess is a bacterial infection that is localized and characterized by pus. Treatment consists of surgical drainage or excision with the concurrent administration of antibiotics.
• Dehiscence (disruption of the surgical wound) and evisceration (protrusion of wound contents): This condition results from sutures giving way, infection, distention, or cough. Dehiscence results in pain; the surgeon is called immediately. Prophylactically, an abdominal binder may be utilized.
• Keloid: refers to excessive growth of scar tissue. Careful wound closure, hemostasis, and pressure support are used to ward off this complication.

Normal results

The goals of wound care include reducing risks that inhibit wound healing, enhancing the healing process, and lowering the incidence of wound infections.

Resources

books

dipietro, luisa a. and aime l. burns, eds. wound healing: methods and protocols (methods in molecular medicine ser). totowa, nj: humana press, 2003.

herndon, david, ed. total burn care, 2nd ed. london: w. b. saunders co., 2001.

hess, cathy thomas. clinical guide to wound care, 4th ed. philadelphia, pa: lippincott williams & wilkins, 2002.

hess, cathy thomas and richard salcido. wound care, 3rd ed. springhouse, pa: springhouse pub co., 2000.

periodicals

collins, nancy. "obesity and wound healing." advances in wound care 16, no 1. (january/february 2003): 45.

collins, nancy. "vegetarian diets and wound healing." advances in wound care 16, no. 2 (march/april 2003): 65.

mcguckin, maryanne, robert goldman, laura bolton, and richard salcido. "the clinical relevance of microbiology in acute and chronic wounds." advances in wound care 16, no 1. (january/february 2003): 12.

trent, jennifer t., and robert s. kirsner. "wounds and malignancy." advances in wound care 16, no 1. (january/february 2003): 31.

organizations

american burn association. 625 n. michigan ave., suite 1530, chicago, il 60611. (800) 548-2876. fax: (312) 642.9130. e-mail: [email protected]. <http://www.ameriburn.org>.

american diabetes association. 1701 north beauregard street, alexandria, va 22311. (800) 342-2383. e-mail: [email protected]. <http://www.diabetes.org>.

american professional wound care association (apwca). suite #a1-853 second street pike, richboro, pa 18954. (215) 364-4100. fax: (215) 364-1146. e-mail: [email protected]. <http://www.apwca.org>.

national institutes of health. 9000 rockville pike, bethesda, md 20892. (301) 496-4000. email: [email protected]. <http://www.nih.gov>.

other

lippincott williams & wilkins. advances in skin & wound care 2003. [cited april 9, 2003]. <http://www.aswcjournal.com/>.

René A. Jackson, RN Crystal H. Kaczkowski, M. Sc.

Wounds

Definition

A wound occurs when the integrity of any tissue is compromised (e.g. skin breaks, muscle tears, burns, or bone fractures ). A wound may be caused by an act, such as a gunshot, fall, or surgical procedure; by an infectious disease; or by an underlying condition.

Description

Types and causes of wounds are wide ranging, and health care professionals have several different ways of classifying them. They may be chronic, such as the skin ulcers caused by diabetes mellitus, or acute, such as a gunshot wound or animal bite. Wounds may also be referred to as open, in which the skin has been compromised and underlying tissues are exposed, or closed, in which the skin has not been compromised, but trauma to underlying structures has occurred (e.g. a bruised rib or cerebral contusion). Emergency personnel and first-aid workers generally place acute wounds in one of eight categories:

• Abrasions. Also called scrapes, they occur when the skin is rubbed away by friction against another rough surface (e.g. rope burns and skinned knees).
• Avulsions. Occur when an entire structure or part of it is forcibly pulled away, such as the loss of a permanent tooth or an ear lobe. Explosions, gunshots, and animal bites may cause avulsions.
• Contusions. Also called bruises, these are the result of a forceful trauma that injures an internal structure without breaking the skin. Blows to the chest, abdomen, or head with a blunt instrument (e.g. a football or a fist) can cause contusions.
• Crush wounds. Occur when a heavy object falls onto a person, splitting the skin and shattering or tearing underlying structures.
• Cuts. Slicing wounds made with a sharp instrument, leaving even edges. They may be as minimal as a paper cut or as significant as a surgical incision.
• Lacerations. Also called tears, these are separating wounds that produce ragged edges. They are produced by a tremendous force against the body, either from an internal source as in childbirth, or from an external source like a punch.
• Missile wounds. Also called velocity wounds, they are caused by an object entering the body at a high speed, typically a bullet.

• Punctures. Deep, narrow wounds produced by sharp objects such as nails, knives, and broken glass.

Causes and symptoms

Acute wounds have a wide range of causes. Often, they are the unintentional results of motor vehicle accidents, falls, mishandling of sharp objects, or sports-related injury. Wounds may also be an intentional result of violence involving assault with weapons, including fists, knives, or guns.

The general symptoms of a wound are localized pain and bleeding. Specific symptoms include:

• An abrasion usually appears as lines of scraped skin with tiny spots of bleeding.
• An avulsion has heavy, rapid bleeding and a noticeable absence of tissue.
• A contusion may appear as a bruise beneath the skin or may appear only on imaging tests; an internal wound may also generate symptoms such as weakness, perspiration, and pain.
• A crush wound may have irregular margins like a laceration; however, the wound will be deeper and trauma to muscle and bone may be apparent.
• A cut may have little or profuse bleeding depending on its depth and length; its even edges readily line up.
• A laceration too may have little or profuse bleeding; the tissue damage is generally greater and the wound's ragged edges do not readily line up.
• A missile entry wound may be accompanied by an exit wound, and bleeding may be profuse, depending on the nature of the injury.
• A puncture wound will be greater than its length, therefore there is usually little bleeding around the outside of the wound and more bleeding inside, causing discoloration.

Diagnosis

A diagnosis is made by visual examination and may be confirmed by a report of the causal events. Medical personnel will also assess the extent of the wound and the effect it has had on the patient's well being (e.g. profound blood loss, damage to the nervous system or skeletal system).

Treatment

Treatment of wounds involves stopping any bleeding, then cleaning and dressing the wound to prevent infection. Additional medical attention may be required if the effects of the wound have compromised the body's ability to function effectively.

Stopping the bleeding

Most bleeding may be stopped by direct pressure. Direct pressure is applied by placing a clean cloth or dressing over the wound and pressing the palm of the hand over the entire area. This limits local bleeding without disrupting a significant portion of the circulation. The cloth absorbs blood and allows clot formation; the clot should not be disturbed, so if blood soaks through the cloth, another cloth should be placed directly on top rather than replacing the original cloth.

If the wound is on an arm or leg that does not appear to have a broken bone, the wound should be elevated to a height above the person's heart while direct pressure is applied. Elevating the wound allows gravity to slow down the flow of blood to that area.

If severe bleeding cannot be stopped by direct pressure or with elevation, the next step is to apply pressure to the major artery supplying blood to the area of the wound. In the arm, pressure would be applied to the brachial artery by pressing the inside of the upper arm against the bone. In the leg, pressure would be applied to the femoral artery by pressing on the inner crease of the groin against the pelvic bone.

If the bleeding from an arm or leg is so extreme as to be life-threatening and if it cannot be stopped by any other means, a tourniquet may be required. However, in the process of limiting further blood loss, the tourniquet also drastically deprives the limb tissues of oxygen. As a result, the patient may live but the limb may die.

In 2004, a new solution to stopping bleeding was reported. Called QuikClot, the FDA-approved substance is made up of synthetically made material called zeolite, which occurs naturally in volcanic rock. When used properly, it can be poured into a wound that will not stop bleeding and will slow blood loss. The trauma pack costs about $50 and has shown particular promise in the battlefield and in wilderness situations.

Dressing the wound

Once the bleeding has been stopped, cleaning and dressing the wound is important for preventing infection. Although the flowing blood flushes debris from the wound, running water should also be used to rinse away dirt. Embedded particles such as wood slivers and glass splinters, if not too deep, may be removed with a needle or pair of tweezers that has been sterilized in rubbing alcohol or in the heat of a flame. Once the wound has been cleared of foreign material and washed, it should be gently blotted dry, with care not to disturb the blood clot. An antibiotic ointment may be applied. The wound should then be covered with a clean dressing and bandaged to hold the dressing in place.

Getting medical assistance

A person who has become impaled on a fixed object, such as a fence post or a stake in the ground, should only be moved by emergency medical personnel. Foreign objects embedded in the eye should only be removed by a doctor. Larger penetrating objects, such as a fishhook or an arrow, should only be removed by a doctor to prevent further damage as they exit.

Additional medical attention is necessary in several instances. Wounds which penetrate the muscle beneath the skin should be cleaned and treated by a doctor. Such a wound may require stitches to keep it closed during healing. Some deep wounds which do not extend to the underlying muscle may only require butterfly bandages to keep them closed during healing. Wounds to the face and neck, even small ones, should always be examined and treated by a doctor to preserve sensory function and minimize scarring. Deep wounds to the hands and wrists should be examined for nerve and tendon damage. Puncture wounds may require a tetanus shot to prevent serious infection. Animal bites should always be examined and the possibility of rabies infection determined.

Infection

Wounds that develop signs of infection should also be brought to a doctor's attention. Signs of infection are swelling, redness, tenderness, throbbing pain, localized warmth, fever, swollen lymph glands, the presence of pus either in the wound or draining from it, and red streaks spreading away from the wound.

Emergency treatment

With even as little as one quart of blood lost, a person may lose consciousness and go into traumatic shock. Because this is life-threatening, emergency medical assistance should be called immediately. If the person stops breathing, artificial respiration (also called mouth-to-mouth resuscitation or rescue breathing) should be administered. In the absence of a pulse, cardiopulmonary resuscitation (CPR) must be performed. Once the person is breathing unassisted, the bleeding may be attended to.

In cases of severe blood loss, medical treatment may include the intravenous replacement of body fluids. This may be infusion with saline or plasma, or a transfusion of whole blood.

In some cases, clinicians have resorted to a Civil War-era treatment that does not sound appealing, but works well enough to receive FDA approval. Maggots can be placed on wounds that refuse to heal with high-tech medical methods. The maggots are dropped into the wound and covered with special mesh to keep them in place. They are removed in two to three days.

Alternative treatment

In addition to the conventional treatments described above, there are alternative therapies that may help support the injured person. Homeopathy can be very effective in acute wound situations. Ledum (Ledum palustre) is recommended for puncture wounds (taken internally). Calendula (Calendula officinalis ) is the primary homeopathic remedy for wounds. An antiseptic, it is used topically as a succus (juice), tea, or salve. Another naturally occurring antiseptic is tea tree oil (Melaleuca spp.), which can be mixed with water for cleaning wounds. Aloe (Aloe barbadensis ) can be applied topically to soothe skin during healing. When wounds affect the nerves, especially in the arms and legs, St.-John's-wort (Hypericum perforatum ) can be helpful when taken internally or applied topically. Acupuncture can help support the healing process by restoring the energy flow in the meridians that have been affected by the wound. In some cases, vitamin E taken orally or applied topically can speed healing and prevent scarring.

Prognosis

Without the complication of infection, most wounds heal well with time. Depending on the depth and size of the wound, it may or may not leave a visible scar.

KEY TERMS

Abrasion— Also called a scrape. The rubbing away of the skin surface by friction against another rough surface.

Avulsion— The forcible separation of a piece from the entire structure.

Butterfly bandage— A narrow strip of adhesive with wider flaring ends (shaped like butterfly wings) used to hold the edges of a wound together while it heals.

Cut— Separation of skin or other tissue made by a sharp edge, producing regular edges.

Laceration— Also called a tear. Separation of skin or other tissue by a tremendous force, producing irregular edges.

Plasma— The straw-colored fluid component of blood, without the other blood cells.

Puncture— An injury caused by a sharp, narrow object deeply penetrating the skin.

Tourniquet— A device used to control bleeding, consisting of a constricting band applied tightly around a limb above the wound. It should only be used if the bleeding in life-threatening and can not be controlled by other means.

Traumatic shock— A condition of depressed body functions as a reaction to injury with loss of body fluids or lack of oxygen. Signs of traumatic shock include weak and rapid pulse, shallow and rapid breathing, and pale, cool, clammy skin.

Whole blood— Blood that contains red blood cells, white blood cells, and platelets in plasma.

Prevention

Most actions that result in wounds are preventable. Injuries from motor vehicle accidents may be reduced by wearing seat belts and placing children in size-appropriate car seats in the back seat. Sharp, jagged, or pointed objects or machinery parts should be used according to the manufacturer's instructions and only for their intended purpose. Firearms and explosives should be used only by adults with explicit training; they should also be kept locked and away from children. Persons engaging in sports, games, and recreational activities should wear all proper protective equipment and follow safety rules.

Resources

PERIODICALS

"Maggots Make Medical Comeback for Healing Wounds." Health & Medicine Week August 23, 2004: 287.

Thornton, Jim. "Stop the Bleeding! An Innovative Treatment for Wilderness Wounds" Field & Stream September 1, 2004: 48.

ORGANIZATIONS

American Red Cross. P.O. Box 37243, Washington, D.C. 20013. 〈http://www.redcross.org〉.

Wounds

Definition

A wound occurs when the integrity of any tissue is compromised (e.g. skin breaks, muscle tears, burns , or bone fractures ). A wound may be caused by an act (such as a gunshot, a fall, or a surgical procedure), by an infectious disease, or by an underlying condition.

Description

Types and causes of wounds are wide ranging, and healthcare professionals have several different ways of classifying them. They may be chronic, such as the skin ulcers caused by diabetes mellitus ; or acute, such as a gunshot wound or animal bite. Wounds may also be referred to as open, in which the skin has been compromised and underlying tissues are exposed, or closed, in which the skin has not been compromised, but trauma to underlying structures has occurred (e.g. a bruised rib or cerebral contusion). Emergency personnel and first-aid workers generally place acute wounds in one of eight categories:

• Abrasions. Also called scrapes, they occur when the skin is rubbed away by friction against another rough surface (e.g. rope burns and skinned knees).
• Avulsions. These occur when an entire structure or part of it is forcibly pulled away, such as the loss of a permanent tooth or an ear lobe. Explosions, gunshots, and animal bites may cause avulsions.
• Contusions. Also called bruises , these are the result of a forceful trauma that injures an internal structure without breaking the skin. Blows to the chest, abdomen, or head with a blunt instrument (e.g. a football or a fist) can cause contusions.
• Crush wounds. These occur when a heavy object falls onto a person, splitting the skin and shattering or tearing underlying structures.
• Cuts. These slicing wounds are made with a sharp instrument, leaving even edges. They may be as minimal as a paper cut or as significant as a surgical incision.
• Lacerations. Also called tears, these are separating wounds that produce ragged edges. They are produced by a tremendous force against the body, either from an internal source as in childbirth , or from an external source like a punch.
• Missile wounds. Also called velocity wounds, they are caused by an object entering the body at a high speed, typically a bullet.
• Punctures. These deep, narrow wounds are produced by sharp objects such as nails, knives, and broken glass.

Demographics

Wounds are very common. Nearly everyone has had a wound of one type or another. Minor wounds are especially common in childhood because children engage in so much rough-and-tumble play .

Causes and symptoms

Acute wounds have a wide range of causes. Often they are the unintentional results of motor vehicle accidents, falls, mishandling of sharp objects, or sports-related injury. Wounds may also be an intentional result of violence involving assault with weapons, including fists, knives, or guns.

The general symptoms of a wound are localized pain and bleeding. Specific symptoms include the following:

• An abrasion usually appears as lines of scraped skin with tiny spots of bleeding.
• An avulsion has heavy, rapid bleeding and a noticeable absence of tissue.
• A contusion may appear as a bruise beneath the skin or may appear only on imaging tests. An internal wound may also generate symptoms such as weakness, perspiration, and pain.
• A crush wound may have irregular margins like a laceration; however, the wound will be deeper and trauma to muscle and bone may be apparent.
• A cut may have little or profuse bleeding depending on its depth and length. Its even edges readily line up.
• A laceration too may have little or profuse bleeding, the tissue damage is generally greater, and the wound's ragged edges do not readily line up.
• A missile entry wound may be accompanied by an exit wound, and bleeding may be profuse, depending on the nature of the injury.
• A puncture wound's depth will be greater than its length; therefore, there is usually little bleeding around the outside of the wound and more bleeding inside, causing discoloration.

When to call the doctor

A child who has become impaled on a fixed object, such as a fence post or a stake in the ground, should only be moved by emergency medical personnel. Foreign objects embedded in the eye should only be removed by a doctor. Larger penetrating objects, such as a fishhook or an arrow, should only be removed by a doctor to prevent further damage as they exit.

Many times wounds can be treated at home; however, additional medical attention is necessary in several instances. Wounds which penetrate the muscle beneath the skin should be cleaned and treated by a doctor. Such a wound may require stitches to keep it closed during healing. Some deep wounds that do not extend to the underlying muscle may only require butterfly bandages to keep them closed during healing. Wounds to the face and neck, even small ones, should always be examined and treated by a doctor to preserve sensory function and minimize scarring. Deep wounds to the hands and wrists should be examined for nerve and tendon damage. Puncture wounds may require a tetanus shot to prevent serious infection. Animal bites should always be examined and the possibility of rabies infection determined.

Infection

Wounds that develop signs of infection should also be brought to a doctor's attention. Signs of infection are swelling, redness, tenderness, throbbing pain, localized warmth, fever , swollen lymph glands, the presence of pus either in the wound or draining from it, and red streaks spreading away from the wound.

Emergency treatment

Even with the loss of less than one quart of blood, a child may lose consciousness and go into traumatic shock. Because this condition is life-threatening, emergency medical assistance should be called immediately. If the child stops breathing, artificial respiration (also called mouth-to-mouth resuscitation or rescue breathing) should be administered. In the absence of a pulse, cardiopulmonary resuscitation (CPR) must be performed. Once the child is breathing unassisted, the bleeding may be attended to.

In cases of severe blood loss, medical treatment may include the intravenous replacement of body fluids. This treatment may be infusion with saline or plasma or a transfusion of whole blood.

Diagnosis

A diagnosis is made by visual examination and may be confirmed by a report of the causal events. Medical personnel will also assess the extent of the wound and what effect it has had on the patient's well being.

Treatment of wounds involves stopping any bleeding then cleaning and dressing the wound to prevent infection. Additional medical attention may be required if the effects of the wound have compromised the body's ability to function effectively.

Treatment

Stopping the bleeding

Most bleeding may be stopped by direct pressure. Direct pressure is applied by placing a clean cloth or dressing over the wound and pressing the palm of the hand over the entire area. This pressure limits local bleeding without disrupting a significant portion of the circulation. The cloth absorbs blood and allows clot formation. The clot should not be disturbed, so if blood soaks through the cloth, another cloth should be placed directly on top rather than replacing the original cloth.

If the wound is on an arm or leg that does not appear to have a broken bone, the wound should be elevated to a height above the child's heart while direct pressure is applied. Elevating the wound allows gravity to slow down the flow of blood to that area.

If severe bleeding cannot be stopped by direct pressure or with elevation, the next step is to apply pressure to the major artery supplying blood to the area of the wound. In the arm, pressure would be applied to the brachial artery by pressing the inside of the upper arm against the bone. In the leg, pressure would be applied to the femoral artery by pressing on the inner crease of the groin against the pelvic bone.

If the bleeding from an arm or leg is so extreme as to be life-threatening and if it cannot be stopped by any other means, a tourniquet may be required. However, in the process of limiting further blood loss, the tourniquet also drastically deprives the limb tissues of oxygen. As a result, the patient may live but the limb may die.

Dressing the wound

Once the bleeding has been stopped, cleaning and dressing the wound is important for preventing infection. Although the flowing blood flushes debris from the wound, running water should also be used to rinse away dirt. Embedded particles such as wood slivers and glass splinters, if not too deep, may be removed with a needle or pair of tweezers that has been sterilized in rubbing alcohol or in the heat of a flame. Once the wound has been cleared of foreign material and washed, it should be gently blotted dry, with care not to disturb the blood clot. An antibiotic ointment may be applied. The wound should then be covered with a clean dressing and bandaged to hold the dressing in place.

Alternative treatment

In addition to the conventional treatments described above, there are alternative therapies that may help support the injured person. Homeopathy can be very effective in acute wound situations. Ledum (Ledum palustre ) is recommended for puncture wounds (taken internally). Calendula (Calendula officinalis ) is the primary homeopathic remedy for wounds. An antiseptic, it is used topically as a succus (juice), tea, or salve. Another naturally occurring antiseptic is tea tree oil (Melaleuca spp.), which can be mixed with water for cleaning wounds. Aloe (Aloe barbadensis ) can be applied topically to soothe skin during healing. When wounds affect the nerves, especially in the arms and legs, St. John's wort (Hypericum perforatum ) can be helpful when taken internally or applied topically. Acupuncture can help support the healing process by restoring the energy flow in the meridians that have been affected by the wound. In some cases, vitamin E taken orally or applied topically can speed healing and prevent scarring.

Prognosis

Without the complication of infection, most wounds heal well with time. Depending on the depth and size of the wound, it may or may not leave a visible scar. Individuals with certain underlying diseases such as diabetes mellitus may have more difficulty healing.

Prevention

Most actions that result in wounds are preventable. Injuries from motor vehicle accidents may be reduced by wearing seat belts and placing children in size-appropriate car seats in the back seat. Sharp, jagged, or pointed objects or machinery parts should be used according to the manufacturer's instructions and only for their intended purpose. Firearms and explosives should be used only by adults with explicit training; they should also be kept locked and away from children. Children engaging in sports , games, and recreational activities should wear proper protective equipment and follow safety rules.

Parental concerns

Children need to be instructed not to pick at scabs, because it slows the healing process and increases the risk of infection. Wounds tend to occur often during childhood, but most of them are minor and can successfully be treated at home.

KEY TERMS

Abrasion —Also called a scrape. The rubbing away of the skin surface by friction against another rough surface.

Avulsion —The forcible separation of a piece from the entire structure.

Butterfly bandage —A narrow strip of adhesive with wider flaring ends (shaped like butterfly wings) used to hold the edges of a wound together while it heals.

Cut —A slicing wound made with a sharp instrument, leaving even edges.

Laceration —A cut or separation of skin or other tissue by a tremendous force, producing irregular edges. Also called a tear.

Plasma —A watery fluid containing proteins, salts, and other substances that carries red blood cells, white blood cells, and platelets throughout the body. Plasma makes up 50% of human blood.

Puncture —An injury caused by a sharp, narrow object deeply penetrating the skin.

Tourniquet —Any device that is used to compress a blood vessel to stop bleeding or as part of collecting a blood sample. Phlebotomists usually use an elastic band as a tourniquet.

Traumatic shock —A condition of depressed body functions as a reaction to injury with loss of body fluids or lack of oxygen. Signs of traumatic shock include weak and rapid pulse, shallow and rapid breathing, and pale, cool, clammy skin.

Whole blood —Blood which contains red blood cells, white blood cells, and platelets in plasma.

Resources

BOOKS

Baranoski, Sharon, et al. Wound Care Essentials: Practice Principles. Philadelphia: Lippincott Williams & Wilkins, 2004.

Brown, Pamela A., et al. Quick Reference to Wound Care. Sudbury, MA: Jones & Bartlett Publishers, 2005.

ORGANIZATIONS

American Medical Association. 515 N. State Street Chicago, IL 60610. Web site: <http://www.ama-assn.org>.

Tish Davidson, A.M. Bethany Thivierge

Wounds

Definition

A wound occurs when the integrity of any tissue is compromised, for example, when skin breaks, muscle tears, burns , or bone fractures . A wound may be caused by an act, such as a gunshot, fall, or surgical procedure; by an infectious disease; or by an underlying condition.

Description

Types and causes of wounds are wide ranging, and health care professionals have several different ways of classifying them. They may be chronic, such as the skin ulcers caused by diabetes mellitus , or acute, such as a gunshot wound or animal bite. Wounds may also be referred to as open, in which the skin has been compromised and underlying tissues are exposed, or closed, in which the skin has not been compromised, but trauma to underlying structures has occurred, such as a bruised rib or cerebral contusion. Emergency personnel and first-aid workers generally place acute wounds in one of eight categories:

• Abrasions. Also called scrapes, they occur when the skin is rubbed away by friction against another rough surface (e.g. rope burns and skinned knees).
• Avulsions. These occur when an entire structure or part of it is forcibly pulled away, such as the loss of a permanent tooth or an ear lobe. Explosions, gunshots, and animal bites may cause avulsions.
• Contusions. Also called bruises , these result from forceful trauma that injures an internal structure without breaking the skin. Blows to the chest, abdomen, or head with a blunt instrument (e.g. a football or a fist) can cause contusions.
• Crush wounds occur when a heavy object falls onto a person, splitting the skin and shattering or tearing underlying structures.
• Cuts are slicing wounds made with a sharp instrument, leaving even edges. They may be as minimal as a paper cut or as significant as a surgical incision.
• Lacerations. Also called tears, these are separating wounds that produce ragged edges. They are produced by a tremendous force against the body, either from an internal source as in childbirth , or from an external source like a punch.
• Missile wounds. Also called velocity wounds, they are caused by an object entering the body at a high speed, typically a bullet.
• Punctures are deep, narrow wounds produced by sharp objects such as nails, knives, and broken glass.

Causes & symptoms

Acute wounds have a wide range of causes. Often, they are the unintentional results of motor vehicle accidents, falls, mishandling of sharp objects, or sports-related injury. Wounds may also be the intentional result of violence involving assault with weapons, including fists, knives, or guns.

The general symptoms of a wound are localized pain and bleeding. Specific symptoms include:

• An abrasion usually appears as lines of scraped skin with tiny spots of bleeding.
• An avulsion has heavy, rapid bleeding and a noticeable absence of tissue.

• A contusion may appear as a bruise beneath the skin or may appear only on imaging tests; an internal wound may also generate symptoms such as weakness, perspiration, and pain.
• A crush wound may have irregular margins like a laceration; however, the wound will be deeper and trauma to muscle and bone may be apparent.
• A cut may have little or profuse bleeding depending on its depth and length; its even edges readily line up.
• A laceration too may have little or profuse bleeding; the tissue damage is generally greater and the wound's ragged edges do not readily line up.
• A missile entry wound may be accompanied by an exit wound, and bleeding may be profuse, depending on the nature of the injury.
• A puncture wound will be greater than its length, therefore there is usually little bleeding around the outside of the wound and more bleeding inside, causing discoloration.

Diagnosis

A diagnosis is made by visual examination and may be confirmed by a report of the causal events. Medical personnel will also assess the extent of the wound and what effect it has had on the patient's well-being (e.g. profound blood loss, damage to the nervous system or skeletal system). In cases of severe injury, or when a physician suspects possible internal injury, tests might be made to determine the extent of a wound. In late 2001, a new ultrasound (imaging inside the body via sound waves) technique was introduced that might help doctors diagnose internal bleeding, a serious complication of some injuries. The technique could help prevent invasive surgery for diagnosis.

Treatment

Treatment of wounds involves stopping any bleeding, then cleaning and dressing the wound to prevent infection. Additional medical attention may be required if the effects of the wound have compromised the body's ability to function effectively.

Stopping the bleeding

Most bleeding may be stopped by direct pressure. Direct pressure is applied by placing a clean cloth or dressing over the wound and pressing the palm of the hand over the entire area. This limits local bleeding without disrupting a significant portion of the circulation. The cloth absorbs blood and allows clot formation; the clot should not be disturbed, so if blood soaks through the cloth, another cloth should be placed directly on top rather than replacing the original cloth.

If the wound is on an arm or leg that does not appear to have a broken bone, the wound should be elevated to a height above the person's heart while direct pressure is applied. Elevating the wound allows gravity to slow down the flow of blood to that area.

If severe bleeding cannot be stopped by direct pressure or with elevation, the next step is to apply pressure to the major artery supplying blood to the area of the wound. In the arm, pressure would be applied to the brachial artery by pressing the inside of the upper arm against the bone. In the leg, pressure would be applied to the femoral artery by pressing on the inner crease of the groin against the pelvic bone.

If the bleeding from an arm or leg is so extreme as to be life-threatening and if it cannot be stopped by any other means, a tourniquet—a device used to check or prevent bleeding or blood flow—may be required. However, in the process of limiting further blood loss, the tourniquet also drastically deprives the limb tissues of oxygen. As a result, the patient may live but the limb may die.

Dressing the wound

Once the bleeding has been stopped, cleaning and dressing the wound is important for preventing infection. Although the flowing blood flushes debris from the wound, running water should also be used to rinse away dirt. Embedded particles such as wood slivers and glass splinters, if not too deep, may be removed with a needle or pair of tweezers that has been sterilized in rubbing alcohol or in the heat of a flame. Once the wound has been cleared of foreign material and washed, it should be gently blotted dry, with care not to disturb the blood clot. An antibiotic ointment may be applied. The wound should then be covered with a clean dressing and bandaged to hold the dressing in place.

Homeopathic remedies

In addition to the conventional treatments described above, there are alternative therapies that may help support the injured person. Homeopathy can be very effective in acute wound situations. Ledum (Ledum palustre ) is recommended for puncture wounds (taken internally). Calendula (Calendula officinalis ) is the primary homeopathic remedy for wounds.

Other effective treatments

A naturally occurring antiseptic is tea tree oil (Melaleuca spp.), which can be mixed with water for cleaning wounds. Aloe (Aloe barbadensis ) can be applied topically to soothe skin during healing. When wounds affect the nerves, especially in the arms and legs, St. John's wort (Hypericum perforatum ) can be helpful when taken internally or applied topically. Also, an important Chinese herb preparation called Yunnan Bai Yao, which includes the main herbal ingredient san chi, is used very effectively to stop bleeding, and promote healing for all sorts of wounds. Other herbal remedies include Hypericum for nerve pain, and arnica for soft tissue damage. Acupuncture can help support the healing process by restoring the energy flow in the meridians that have been affected by the wound. In some cases, vitamin E taken orally or applied topically can speed healing and lessen scarring.

Allopathic treatment

A person who has become impaled on a fixed object, such as a fence post or a stake in the ground, should only be moved by emergency medical personnel. Foreign objects embedded in the eye should only be removed by a doctor. Larger penetrating objects, such as a fishhook or an arrow, should only be removed by a doctor to prevent further damage as they exit.

Additional medical attention is necessary in several instances. Wounds that penetrate the muscle beneath the skin should be cleaned and treated by a doctor. Such a wound may require stitches to keep it closed during healing. Some deep wounds, which do not extend to the underlying muscle may only require butterfly bandages to keep them closed during healing. Wounds to the face and neck, even small ones, should always be examined and treated by a doctor to preserve sensory function and minimize scarring. Deep wounds to the hands and wrists should be examined for nerve and tendon damage. Puncture wounds may require a tetanus shot to prevent serious infection. Animal bites should always be examined and the possibility of rabies infection determined.

Infection

Wounds that develop signs of infection should also be brought to a doctor's attention. Signs of infection are swelling, redness, tenderness, throbbing pain, localized warmth, fever , swollen lymph glands, the presence of pus either in the wound or draining from it, and red streaks spreading away from the wound.

Emergency treatment

With even as little as one quart of blood lost, a person may lose consciousness and go into traumatic shock. Because this is life-threatening, emergency medical assistance should be called immediately. If the person stops breathing, artificial respiration (also called mouth-to-mouth resuscitation or rescue breathing) should be administered. In the absence of a pulse, cardiopulmonary resuscitation (CPR) must be performed. Once the person is breathing unassisted, the bleeding may be attended to.

In cases of severe blood loss, medical treatment may include the intravenous replacement of body fluids. This may be infusion with saline or plasma, or a transfusion of whole blood.

Expected results

Without the complication of infection, most wounds heal well with time. Depending on the depth and size of the wound, it may or may not leave a visible scar.

Prevention

Most actions that result in wounds are preventable. Injuries from motor vehicle accidents may be reduced by wearing seat belts and placing children in size-appropriate car seats in the back seat. Sharp, jagged, or pointed objects or machinery parts should be used according to the manufacturer's instructions and only for their intended purpose, as well as educating children on the proper way to hold and handle them, or keeping them out from their reach. Firearms and explosives should be used only by adults with explicit training; they should also be kept locked and away from children. Persons engaging in sports, games, and recreational activities should wear all proper protective equipment and follow safety rules.

Resources

BOOKS

American Red Cross Staff. Standard First Aid. St. Louis: Mosby Yearbook, 1992.

The Editors of Time-Life Books. The Medical Advisor: The Complete Guide to Alternative and Conventional Treatments. Alexandria, VA: Time-Life Books, 1996.

PERIODICALS

"Sound Waves Beat the Knife." The Economist (December 8, 2001).

ORGANIZATIONS

American Red Cross. P.O. Box 37243, Washington, D.C. 20013. http://www.redcross.org.

Kathleen Wright

Teresa G. Odle

Laceration Repair

Definition
Purpose
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Alternatives

Definition

Laceration repair includes all the steps required to treat a wound in order to promote healing and minimize the risks of infection, premature splitting of sutures (dehiscence), and poor cosmetic result.

Purpose

A laceration is a wound caused by a sharp object producing edges that may be jagged, dirty, or bleeding. Lacerations most often affect the skin, but any tissue may be lacerated, including subcutaneous fat, tendon, muscle, or bone.

A laceration should be repaired if it:

• Continues to bleed after application of pressure for10-15 minutes.
• Is more than one-eighth (0.125 in, or 0.3 cm) to one-fourth inch (0.25 in, or 0.6 cm) deep.
• Exposes fat, muscle, tendon, or bone.
• Causes a change in function surrounding the area of the laceration.
• Is dirty or has visible debris in it.
• Is located in an area where an unsightly scar is undesirable.

Lacerations are less likely to become infected if they are repaired soon after they occur. Many physicians will not repair a laceration that is more than eight hours old because the risk of infection is too great.

Description

Laceration repair mends a tear in the skin or other tissue. The four goals of laceration repair are to stop bleeding, prevent infection, preserve function, and restore appearance.

The laceration is cleaned by removing any foreign material or debris. Removing foreign objects from penetrating wounds can sometimes cause bleeding, so this type of wound must be cleaned very carefully. The wound is then irrigated with saline solution and a disinfectant. The disinfecting agent may be mild soap or a commercial preparation. An antibacterial agent may be applied.

Once the wound has been cleansed, the physician anesthetizes the area of the repair. Most lacerations are anesthetized by local injection of lidocaine, with or without epinephrine, into the wound edges. Lidocaine without epinephrine is used in areas with limited blood supply such as fingers, toes, ears, penis, and nose, because epinephrine could cause constriction of blood vessels (vasoconstriction) and interfere with the supply of blood to the laceration site. Alternatively, a topical anesthetic combination such as lidocaine, epinephrine, and tetracaine may also be used.

The physician may trim edges that are jagged or extremely uneven. Tissue that is too damaged to heal must be removed (debridement ) to prevent infection. If the laceration is deep, several absorbable stitches (sutures) are placed in the tissue under the skin to help bring the tissue layers together. Suturing also helps eliminate any pockets where tissue fluid or blood can accumulate. The skin wound is closed with sutures. Suture material used on the surface of a wound is usually non-absorbable and will have to be removed later. A light dressing or an adhesive bandage is applied for 24-48 hours. In areas where a dressing is not feasible, an antibiotic ointment can be applied. If the laceration is the result of a human or animal bite, if it is very dirty, or if the patient has a medical condition that alters wound healing, a broad-spectrum antibiotic may be prescribed.

Newer types of laceration repair do not require sutures. Materials such as staples or dermabond glue

may be used to hold the edges of a laceration together, allowing the edges to knit together.

Diagnosis/Preparation

Preparation for laceration repair involves inspecting the wound and the underlying tendons or nerves to evaluate the risk of infection, the degree of tissue

damage, the need for debridement, and its complexity. If hair is located in or around the wound, it is usually removed to minimize contamination and allow for good visibility of the wound. If nerves or tendons have been injured, a surgeon may be needed to complete the repair.

Aftercare

The laceration is kept clean and dry for at least 24 hours after the repair. Light bathing is generally permitted after 24 hours if the wound is not soaked. The physician will provide directions for any special wound care. Sutures are removed three to 14 days after the repair is completed. Timing of suture removal depends on the location of the laceration and physician preference.

The repair should be examined frequently for signs of infection, which include redness, swelling, tenderness, drainage from the wound, red streaks in the skin surrounding the repair, chills, or fever. If any of these occur, the physician should be contacted immediately.

Risks

The most serious risk associated with laceration repair is infection. Risk of infection depends on the nature of the wound and the type of injury sustained. Infection risks are increased in wounds that are contaminated with soil or fecal matter, are the result of bites, have been open longer than one hour, or are located on the extremities or on the region between the thighs, genitalia, or other areas where opposing skin surfaces touch and may rub.

Normal results

All lacerations will heal with a scar. Wounds that are repaired with sutures are less likely to develop scars that are unsightly, but it cannot be predicted how wounds will heal and who will develop unsightly scars. Plastic surgery can improve the appearance of many scars.

Alternatives

The only alternative to laceration repair is to leave the wound without medical treatment. This increases the risk of infection, poor healing, and an undesirable cosmetic result.

KEY TERMS

Debridement— The act of removing any foreign material and damaged or contaminated tissue from a wound to expose surrounding healthy tissue.

Dehiscence— A premature bursting open or splitting along natural or surgical suture lines. A complication of surgery that occurs secondary to poor wound healing.

Laceration— A torn, ragged, mangled wound.

Sutures— Materials used in closing a surgical or traumatic wound.

Vasoconstriction— The diminution of the diameter of blood vessels, leading to decreased blood flow to a part of the body.

Resources

BOOKS

Marx, John A., et al. Rosen’s Emergency Medicine. 6th ed. St. Louis, MO: Mosby, Inc., 2006.

PERIODICALS

Beredjiklian, P. K. “Biologic Aspects of Flexor Tendon Laceration and Repair.” The Journal of Bone and Joint Surgery 85-A (March 2003): 539–550.

Gordon, C. A. “Reducing Needle-stick Injuries with the Use of 2-octyl Cyanoacrylates for Laceration Repair.” Journal of the American Academy of Nurse Practitioners 13 (January 2001): 10–12.

Klein, E. J., D. S. Diekema, C. A. Paris, L. Quan, M. Cohen, and K. D. Seidel. “A Randomized, Clinical Trial of Oral Midazolam Plus Placebo Versus Oral Midazolam Plus Oral Transmucosal Fentanyl for Sedation during Laceration Repair.” Pediatrics 109 (May 2002): 894–897.

Pratt, A. L., N. Burr, and A. O. Grobbelaar. “A Prospective Review of Open Central Slip Laceration Repair and Rehabilitation.” The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand 27 (December 2002): 530–534.

Singer, A. J., J. V. Quinn, H. C. Thode Jr., and J. E. Hollander. “Determinants of Poor Outcome after Laceration and Surgical Incision Repair.” Plastic and Reconstructive Surgery 110 (August 2002): 429–437.

ORGANIZATIONS

The Association of Perioperative Registered Nurses, Inc. (AORN). 2170 South Parker Rd, Suite 300, Denver, CO 80231-5711. (800) 755-2676. http://www.aorn.org/.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Primary care physicians, emergency room physicians, and surgeons usually repair lacerations. All physicians are trained in the basics of wound assessment, cleansing, and anesthesia. They are also familiar with the basic suturing techniques and have the experience required to attend to the details of wound repair, such as proper selection and preparation of equipment, careful wound preparation, appropriate use of specific closure methods, and effective patient education, required to avoid wound infection and excessive scarring.

Laceration repair is routinely performed in hospitals and clinics on an outpatient basis.

QUESTIONS TO ASK THE DOCTOR

• How will my wound be repaired?
• Will the procedure hurt?
• How can I avoid infection after surgery?
• Will I be able to wash the wound?
• What are the possible complications?
• How long will it take to heal?
• Will there be a scar?
• When can the sutures be removed?

OTHER

“Cuts and Scrapes.” Mayo Clinic Online. http://www.mayoclinic.com/invoke.cfm?objectid=FDEFD23A-F29F-47FB-9A7CD4CF4427D590.

“A Systematic Approach to Laceration Repair.” Postgraduate Medicine Page. http://www.postgradmed.com/issues/2000/04_00/wilson.htm.

“Wound Repair.” Family Practice Notebook. http://www.fpnotebook.com/SUR18.htm.

Mary Jeanne Krob, MD, FACS

Monique Laberge, PhD

Rosalyn Carson-DeWitt, MD

Lactate dehydrogenase isoenzymes test seeLiver function tests