Basic Wound Care

[WARNING: Some Pics MAY be *gross*]
Cuts, scrapes, abrasions, lacerations... these are all familiar injuries, not only with outdoor pursuits, but in every day life. The majority of these wounds heal up without much fuss--although there are some specific things to think about with lacerations that need sutures--but there are some common wound care myths out there that I'd like to debunk.

I actually heard one of my colleagues recommending that a wound be "given some air" each day, and I started to cringe, but that's how these misconceptions keep circulating. I'll get to the "airing out" shortly, first let's talk about cleaning the wound.

Wound care first includes cleaning the injury, and the best way to do so is with water irrigation. In the emergency department, we will be fancy and fill a big syringe up with sterile saline and spray the wound, but the reality is that that is no better than irrigating a wound with regular tap water. The main purpose for irrigating a wound is to eliminate contaminants, whether that's on a microscopic level (bacteria), or macroscopic (dirt, leaves, rocks, sand), and that's done by the mechanical force of the water. Actually, in some cases, a wound that bleeds copiously is starting the irrigation process, but the force of the water getting all the dirt and debris out is more important than whether or not sterile saline or water is used. Of course, if your tap water is undrinkable, you may want to reconsider my recommendation.

Really large wounds or especially contaminated wounds *may* benefit from some skilled help (a medical professional manually removing debris or applying a topical anesthetic to help with the cleaning), but MOST wound can easily be cleaned at home in the sink or shower.

Many people think that using hydrogen peroxide is good to clean wounds, but that's simply not true. I had previously enjoyed the bubbling when it hit an open cut, but hydrogen peroxide not only kills pathogens (bad cells), but it also kills healthy tissue. 

According to Dr. Troy Madsen, an ER doc at the University of Utah, "the problem with hydrogen peroxide, it may be killing the germs, but it's also killing the healthy tissue in there too. So that's the biggest challenge with it is we think that we are sterilizing the wound and getting rid of all the bad stuff, but we're also then killing the good tissue in there as well, and that can then cause a larger wound than we would have had otherwise. And quite honestly, that whole process of sterilizing it and killing everything off isn't really necessary. You don't need that. You don't need to make this a completely sterile environment. The body is set up to fight off bacteria and help to heal things, so you're probably doing more harm than good with it."

So there you have it, gentle irrigation is all that's needed to clean most wounds.

Once the wound is cleaned, you'll need to figure out if stitches (sutures) are needed. For the most part, any lacerations that are over an area of tension or are deep or have wound edges that are gaping a bit will probably heal better and faster with sutures. Deep wounds also need to be assessed to determine if any important structures--bone/tendon/nerve/vessel/etc was injured. When it comes to sutures, timing is really important as you'll want to have a wound closed as soon as possible. If a wound is more than 12hrs old, many times the risk of infection goes up if it's stitched, although some wounds can be closed up to 24hrs. Either way, sooner is better. Unfortunately, if you get a wound late in the evening, and the local Urgent Care is closed, you might have to go to the Emergency Department instead of waiting until the next morning.

If you get stitches, you should get good wound care instructions from your healthcare provider, but if the wound is one that you're going to manage on your own, the next step is the bandage.

First, apply a very thin layer of antibiotic ointment and then cover the wound with some type of non-stick bandage. The fact that the ointment is an antibiotic ointment is not as important as the fact that it's going to keep the wound moist. Yes, moist wounds heal faster than ones that are allowed to dry out.

UpToDate, [subscription needed, citation numbers removed below for brevity] which is a trusted reference resource used by healthcare providers around the globe says the following about occluded (covered) vs non-occluded (open to the air) wounds:

Importance of moisture — For much of the history of medicine, it was believed that wounds should not be occluded but left exposed to the air. However, an important study in a pig model showed that moist wounds healed more rapidly compared with wounds that dried out. Similar results have been obtained in humans.

Occluded wounds heal up to 40 percent more rapidly than nonoccluded wounds. This is thought to be due, in part, to easier migration of epidermal cells in the moist environment created by the dressing. Another mechanism for improved wound healing may be the exposure of the wound to its own fluid. Acute wound fluid is rich in platelet-derived growth factor, basic fibroblast growth factor, and has a balance of metalloproteases serving a matrix custodial function. These interact with one another and with other cytokines to stimulate healing. 

It seems that covered wounds do better at reducing scar formation, as UpToDate also states:

In addition to faster wound healing, wounds treated with occlusive dressings are associated with less prominent scar formation. One study of porcine skin found an acceleration in the inflammatory and proliferative phases of healing when wounds were covered with an occlusive dressing as opposed to dry gauze. This "acceleration" through the wound phases may prevent the development of a chronic wound state, which is typically arrested in the inflammatory phase of healing. Wounds that have a greater amount of inflammation tend to result in more significant scars, and thus the decreased inflammation and proliferation seen with wound occlusion may also decrease the appearance of the scar.

With the wound cleaned and covered, now you sit back and the healing take place.

Wounds can get wet, but not soaked for a prolonged period of time. A shower or basic hygiene is great, but don't soak an injury in a tub or pool. Each day the bandage should be taken off so that wound can be cleaned (gentle water irrigation), and then it should be covered again with a thin layer of ointment and nonstick dressing. If the dressing gets dirty, it will need to be changed more often, but usually once a day is good enough. 

You may notice some thick-ish yellow-ish discharge on a wound, and a small amount is okay. That "exudate" is a normal part of the inflammatory/immune response and does NOT mean a wound is infected. 

How do you tell if a wound IS infected and needs antibiotics?

  • Redness is spreading
  • Pain is worsening
  • Fevers or chills
  • Increased swelling 
  • An excessive amount of exudate

These are unlikely to occur in most wounds in people with a normal immune system. People who have problems with their immune system or people who have wounds that are particularly dirty (bites for example) may get antibiotics early, but most people won't need them.

From here, it's just a matter of changing the dressings daily, keeping the wound cleaned and moist, and letting the body do it's thing.

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