Wound dressings - acute traumatic wounds

PIC Endorsed

Key Points

All wound care including cleaning, irrigation and dressings should be managed with an aseptic technique
Initial decontamination of the wound with irrigation is of utmost importance and should be performed prior to dressing
Most wounds do not require antibiotic therapy if cleansed and decontaminated adequately
Provide adequate analgesia during wound care

Background

Objectives of wound care are to:

reduce pain
promote wound healing
reduce infection risk
optimise cosmetic and functional outcome

Actions to achieve this include:

wound cleaning
closure (if appropriate)
dressing
antibiotic prophylaxis (if appropriate)
immobilisation
compression (to achieve haemostasis)

Assessment

History

Mechanism of injury, associated blood loss, risk of contamination, deeper structure damage
Tetanus status
Red flags for child abuse
Underlying chronic illness or disability

Examination

Fully examine the injured part, in particular checking for:

underlying nerve, vessel and tendon damage. This requires assessment of movement while exploring the wound (especially in palmar or hand wounds: see "fight bite")
tissue damage or loss

Assessment of severity

Location of wound
Appearance/presentation. See additional notes for wound bed characteristics
Exudate type and amount
Wound dimensions
Colour
Condition of surrounding skin
Presence of odour

Investigations

Consider X-ray for underlying fracture or radiopaque foreign body eg glass or metal
Consider ultrasound for puncture wounds with a radiolucent foreign body eg thorn or splinter
Consider swab for MCS only if considering antibiotics

Management

Wound cleansing/irrigation is important for decreasing bacterial load. Cleansing/irrigating with antiseptics may damage tissue defences and impede healing. The exception is contaminated wounds that may benefit from chlorhexidine 0.05% or povidine-iodine 1% irrigation

Provide adequate pain management, anaesthesia (see anaesthesia in lacerations) and procedural sedation
Irrigation fluid delivery:
- Use a 20-30 mL syringe with a large bore non bevelled needle filled with 0.9% sodium chloride to slowly irrigate the wound
- Consider use of a splash guard
- Hold the syringe just above the top edge of the wound using continuous gentle pressure to flush fluid
- Thorough irrigation (eg 50-100mL per cm length of wound) is required
Consider referral for plastic or general surgical opinion either in ED or as outpatient for:
- cosmetically sensitive wounds
- deep wounds or wounds with significant tissue loss
- involvement of underlying structures such as tendons, nerves and vessels

Treatment

Most wounds do not require antibiotic therapy
Initial decontamination of wound is more important. See Cellulitis and skin infections
Antibiotics should be reserved for:

animal/human bites
penetrating wounds of vital structures (eg eye)
contaminated wounds especially when deep
severe or contaminated water-wounds
when wound cleaning has been delayed (> 8 hours)
wounds with extensive tissue damage or massive contamination

General Principles of Dressing Selection

Hydrogels for debridement stage
Low adherent moisture maintaining for granulation stage
Low adherent for epithelialisation stage

Type of wounds and dressing options
See burns for burns dressing advice

Wound Type	Dressing Role	Options	Review Time
Graze, abrasions - clean	Keep dry	Film, tulle, fixation sheet or dry	2 days
Graze, abrasions - soiled	Keep dry	Dry or tulle	2 days
Lacerations - sutured/ glued/ closed	Protect and minimise irritation	Open or dry, consider paper tape support following suture removal	3-7 days
Puncture wounds	Keep dry, allow visualisation of wound	Open or dry	1-2 days
Slough – dry	Hydration. Control moisture balance. Promote debridement	Moisture retention eg hydrocolloid, semi permeable
Slough – moist	Fluid absorption. Protect surrounding skin. Promote debridement	Absorbent dressing eg alginate, foam
Necrotic – dry	Hydration. Promote debridement	Moisture retention eg hydrocolloid, semi permeable	3-4 days
Infected wound	Antimicrobial. Moist healing. Odour absorption	Avoid semi occlusive dressings. Consider alginate or hydrocolloid if high exudate	1-2 days
Chronic wounds eg ulcers, PEG site	Moisture retention/fluid absorption	Hydrocolloid, alginate, foam	5 days

Dressing Choices

Dressing types	Examples	Advantages	Disadvantages	Indications	Contraindications
Semi-permeable Thin, adhesive, transparent polyurethrane film	OpSite, Tegaderm	Allows inspection. Self-adhesive. Some moisture evaporation. Reduces pain. Barrier to external contamination	Exudate may pool. May be traumatic to remove. Surrounding skin may become macerated	Superficial wounds. As a secondary dressing	Highly exudative wounds
Non adherent Moist (Tulle Gras Dressing) Gauze impregnated with paraffin or similar. May be impregnated with antiseptics or antibiotics	Jelonet, Unitulle Bactigras, Sofra-Tulle	Reduces adhesion to wound. Moist environment aids healing. Easy to use. Low cost	Do not absorb exudate or maintain moisture. Requires secondary dressing. May induce allergy or delay healing when impregnated	Burns. Wounds healing by secondary intention	Allergy
Non adherent Dry Thin perforated plastic film coating attached to absorbent pad	Melolin, Melolite, Tricose	Low wound adherence. May absorb light exudate	Not suitable in high exudate. Can dry out and stick to wound. Requires secondary dressing	Wounds with moderate exudate	Dry wounds (may cause tissue dehydration)
Fixation Sheet Porous polyester fabric with adhesive backing	Fixomull, Hypafix, Mefix	Can be used directly on wound site. Conforms to body contours, good pain relief and controls oedema. Remains permeable allowing exudate to escape and be washed and dried off wound. Dressing changes can be left for 5-7 days	Dressing needs washing with soap and water, pat-dried twice daily. Requires application of oil prior to removal, ideally soaked in oil and wrapped in cling film overnight	Wounds with mild exudate, not needing frequent review	Infected wounds. Allergy to adhesives
Calcium Alginate Natural polysaccharide from seaweed	Kaltostat	Forms gel on wound and hence moist environment. Reduces pain. Can pack cavities. Absorbent in exudative wounds. Promotes haemostasis. Low allergenic	May require secondary dressing. Not recommended in anaerobic infections. Gel can be confused with slough or pus in wound. Must be removed to monitor wound. Unpleasant odour	Moderately or highly exudative wounds. Need for haemostasis	Dry wounds or hard eschar
Foam Dressings Polyurethane foam dressing with adhesive layer incorporated	PolyMem	Moist, highly absorbent, protective. Can be used to pack cavities	Set size of foam may be limited by wound size. Needs daily change	Wounds with mild to moderate exudate	Dry wounds. Wounds that need frequent review
Hydrocolloid Dressings Polyurethane film coated with adhesive mass	Duoderm, Comfeel	Retains moisture. Painless removal	Malodour. Potential allergic contact dermatitis	Burns (small). Abrasions	Dry wounds. Infection
Hydrogels	Intrasite Gel	Can provide or absorb moisture depending on surrounding tissue. Initially lower temperature providing cooling	May need a secondary adhesive dressing	Dry wounds	Suspected gram-negative infections
Paper adhesive tapes Adhesive tape may be applied directly to healing laceration	Micropore, Steristrips	Non allergenic. Provides wound support	Non absorbent	Small wounds	Exudative or large wounds
Antimicrobial	Acticoat, Aquacel Ag, Idosorb	Decrease bacterial load	Expensive	Infected wounds. Burns	Caution use of iodine dressings in patients with thyroid disease

Post Dressing Care and Discharge instructions

Provide education regarding wound healing, monitoring for signs of infection and scar minimisation strategies, including:

Avoid sun exposure
Scar massage from 2-4 weeks following wound closure/suture removal 5-10 min twice daily
Moisturising creams such as vitamin E, aloe vera and sorbelene can be used to soften scar and make massage easier

Consider consultation with local paediatric team when

Consider consultation with surgical/plastics team when

Wound dressing too complex to complete or specific dressings not available

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

Dressing applied and follow-up plan in place

Parent information

Wound care

Additional notes

Wound Bed Type	Characteristics
Granulation	Pinkish/red coloured moist tissue. Bleeds easily
Epithelializing	Pink, almost white. Only occurs on top of healthy granulation tissue
Slough	Devitalised yellowish tissue. Accumulation of dead cells, not pus
Necrotic	May appear hard, dry and black or grey. Presence of dead tissue prevents healing
Hypergranulating	Granulation tissue growing above wound margin

Images sourced from SCHN wound assessment and management guideline. Available from: https://www.schn.health.nsw.gov.au/_policies/pdf/2014-9040.pdf

Last updated March 2023

Reference List

Armstrong, D et al. Basic Principles of Wound Management. Up To Date.2020. [updated 12/07/2020] (viewed 10 May 2022).

Jaman, J et al. Is the use of specific time cut-off or “golden period” for primary closure of acute traumatic wounds evidence based? A systematic review. Croatian Medical Journal. 2021. 62 pages 614-622.

Jones, V et al. Wound dressings. British Medical Journal (Clinical research ed). 2006. 332(7544), p777–780. https://doi.org/10.1136/bmj.332.7544.777.

Lammers, RL et al. Prediction of traumatic wound infection with a neural network-dervied decision model. American Journal of Emergency Medicine. 2003. 21(1), pages 1-7.

Morgan, WJ et al. The delayed treatment of wounds of the hand and forearm under antibiotic cover. British Journal of Surgery. 1980. 67(2), pages 140-141.

Perth Children’s Hospital. Wound care. https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Wound-care (viewed 10 May 2022).

Shepherd, M & Starship hospital et al. Lacerations and Wound Closure. https://starship.org.nz/guidelines/lacerations-and-wound-closure/ (viewed 10 May 2022).

The Sydney Children’s Hospitals Network. Wound assessment and management: Practice Guideline. https://www.schn.health.nsw.gov.au/_policies/pdf/2014-9040.pdf (viewed 10 May 2022).

Waseem, M et al. Is there a relationship between wound infections and laceration closure times? International Journal of Emergency Medicine. 2012. 5:32.

Wolcott, RD et al. Role of wound cleansing in the management of wounds. Wounds Middle East. 2014. 1(1) p33-38.

The Royal Children's Hospital Melbourne

Clinical Practice Guidelines