Before treating the wound, a decision must be made about whether treatment will be performed by yourself or a specialist. History-taking and examination can help make the right decision. Decision Tree 1 illustrates the steps involved in the decision-making process.
History-Taking and Examination
- First assess the patient’s general condition with regard to vital functions.
- Knowledge of how the wound occurred can help when estimating the amount of non-viable tissue, damage to deeper-lying structures, and the extent of contamination.
- For assessing trauma-related tissue damage, assume that incised wounds, penetration wounds, and abrasions cause little damage.
- Severe tissue damage may be expected for lacerations, contusions, gunshot wounds, burns, fractures, and wounds caused by radiation or electricity. Penetration wounds, gunshot wounds, and fractures can damage deeper-lying structures. Wounds to the chest or abdomen caused by sharp or blunt objects may damage internal organs (even if the skin is intact). Wounds to the extremities caused by sharp or blunt objects can severely damage blood vessels, tendons, joints, nerves, and muscles. Severe contamination may be expected for bite wounds caused by humans or animals. These wounds should never be treated with primary closure.
- Wounds older than 6 hours should be left open. Deviation from this recommendation may be considered when the wound occurs in a very well vascularised area, such as the face.
- Factors that may influence wound healing are: advanced age, systemic disease (diabetes mellitus or atherosclerosis), a neurological disorder, malnutrition, poor vascularisation of the wound area (front side of the lower leg), medication use (corticosteroids, anticoagulants, chemotherapy).
- Has the patient been vaccinated against tetanus?
During the examination, determine the following:
- Patient’s general condition.
- Extent of the wound.
- Degree of contamination.
- Degree of tissue damage.
- Damage to deeper-lying structures.
Approach
Normally, a general practitioner will decide to treat a wound themselves if there are no complicating factors present. This implies the following:
- Wounds with little tissue damage, i.e. damage to deep-lying structures is not suspected, and little contamination can be treated with debridement and primary wound closure.
- The same type of wound with heavy contamination or older than six hours can be treated with debridement; the wound is left open. Delayed primary closure may occur as necessary after 4-7 days.
- Wounds involving high tissue loss, suspected or confirmed damage to deep-lying structures, or areas of cosmetic importance (wounds traversing the skin and lip), should be handled by a specialist. The fact that leaving a wound open is a safe treatment approach is often overlooked. Primary wound closure is associated with a higher risk of infection, particularly when the wound is heavily contaminated. Performing primary closure on an infected wound yields a more prominent scar than what would be expected had the wound been left open.
Follow-Up Care
After a wound is closed, a wound covering bandage or a pressure bandage must be placed over the wound. The wound covering bandage can be removed after four days (after two days, a clean, closed wound is no longer accessible by bacteria). The pressure bandage must be removed within 24 hours.
Patients must be informed of which complications may occur, measures they must take, and where they can seek help.
Patients are advised to return immediately if they experience wound redness, severe and/or throbbing pain, or fever. If infection occurs, treatment options are a wet compress or removal of one or more sutures to drain the wound, depending on the severity of the infection.
This means that the patient must possess a letter describing the treatment that he has undergone, in the event that follow-up care is provided elsewhere or by another colleague (weekend service). Arrangements should also be made with regard to pain control, and instructions should be given on using the operated or injured body part.
To promote wound healing, relative inactivity is recommended. The extent of the wound or a tendency for bleeding may necessitate temporarily immobilising or elevating the affected body part (sling).
If necessary, the patient should receive tetanus prophylaxis. Written proof that the patient received tetanus prophylaxis should be given to the patient, and it should be noted in the patient’s file.
The timing of suture removal depends on the wound site. After 10 days for wounds to the torso or extremities and after 5 days for wounds to the face and neck.