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Wound dressings - acute traumatic wounds

  • See also

    Lacerations
     Burns

    Background

    There are a number of different dressings and techniques available for managing wounds. The majority of wounds in children are acute trauma or surgical wounds.

    Objectives of wound dressing

    • Reduce pain 
    • Apply compression for haemorrhage or venous stasis 
    • Immobilise an injured body part
    • Protect the wound and surrounding tissue
    • Promote moist wound healing

    Assessment

    Elicit a careful history of injury ie: 

    • mechanism of injury; associated blood loss; risk of contamination; deeper structure damage; 
    • tetanus status; 
    • consider Non accidental injury; 
    • underlying chronic illness or disability.

    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).
    • Assess tissue damage or loss

    Investigation

    Request special investigations where appropriate 

    • xray for radiopaque foreign body or underlying fracture  
    • ultrasound is useful for puncture wounds with a radiolucent foreign body such as thorn or splinter.

    Consider referral for plastic or general surgical opinion either in ED or as outpatient

    Management

    Dressing Choices

    Dressing types Examples Advantages Disadvantages Indications Contraindications
    Semi-permeable - thin, adhesive, transparent polyurethrane film OpSite, Tegaderm Some moisture evaporation, Reduces pain. Barrier to external contamination. Allows inspection. Exudate may pool, may be traumatic to remove. 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. Does not absorb exudate. 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. May require 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. 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 and protective Set size of foam may be limited by wound size Wounds with mild to moderate exudate. Dry wounds. Wounds that need frequent review.
    Hydrocolloid Dressings Polyurethane film coated with adhesive mass Duoderm Retains moisture, painless removal. Avoid on high exudate wounds Burns (small) Abrasions Dry wounds Infection
    Paper adhesive tapes Adhesive tape may be applied directly to healing laceration Micropore Non allergenic. Provides wound support Non absorbent Small wounds Exudative or large wounds.

    Decision Tree Types of wounds and dressing options

    Wound Type Dressing options Review times
    Dry necrotic wound Moisture retention eg hydrocolloid, semi permeable 3-4 days
    Slough - covered wounds Moisture retention and fluid absorption eg hydrocolloid, alginate 3-4 days
    Infected wound Avoid semi occlusive dressings. Consider alginate or hydrocolloid if high exudate 1-2 days
    Graze, abrasions - clean Film, tulle, fixation sheet or dry 2 days
    Graze, abrasions - soiled Dry or tulle 2 days
    Puncture wounds or bites Open or dry 2 days
    Laceration - sutured Lacerations Open or dry, consider paper tape support after suture removal 3-7 days
    Burn-minor Burns Film, medicated tulle, fixation sheet 4-5 days visual review leave dressing on if healing see
    Burn-major or requiring admission eg special areas Burns Plastic wrap prior to surgical review, medicated tulle Inpatient review 
    Chronic wounds eg ulcers, PEG sites etc Hydrocolloid, alginate, foam 5 days