Wound management principles

Wound management attempts to promote wound healing, prevent contamination and wound breakdown, and reduce pain and discomfort.

A wound heals through the phases of haemostasis, inflammation, granulation, and maturation.

The first two processes arrest bleeding and help remove contamination.

• Granulation involves rebuilding of the tissues, angiogenesis contraction, and epithelialisation. This process normally takes about 21 days, but may be delayed by age, infection, dehydration, or poor nutrition.

• Maturation may take several years and involves remodelling of the dermis to increase the strength of the healed wound.

A wound that fails to go through these process steps may become chronic. It is important to keep the wound warm and moist since all human cells (with the exception of the dead, keratinised, superfi cial skin cells) require moisture to survive, and warmth to grow and divide. An exudate provides the best environment for healing by supporting cells involved in wound repair with nutrients. Although angiogenesis is increased in a low oxygen environment (e.g. under occlusive dressings), most large, randomised trials

show reduction in post-operative wound infection from administering supplemental oxygen.

Wound cleansing

Wounds should be cleaned by irrigation with isotonic saline. Soaps irritate the wound but may be useful on the surrounding skin. Both iodine and peroxide irritate the wound, are unnecessary, and best avoided.

Wound infection

The hallmarks of wound infection are:

• Pain.

• Redness.

• Increased warmth.

• Tenderness.

• Oedema.

• Purulent discharge.

• Foul odour.

Systemic or spreading signs of infection (e.g. cellulitis) may be present and mandate systemic antibiotic therapy. The wound should be swabbed prior to treatment. Otherwise, local treatments may be sufficient, e.g. silver preparations, iodine-based preparations, and topical antibiotic (e.g. silver sulfadiazine). The latter should only be used for short-term treatment in mild cases. Surgical debridement may occasionally be needed.

Pressure sores

Pressure sores occur due to compression of tissue between bone and the support surface, and due to shearing forces, friction, and maceration of tissues against the support surface. A pressure sore requires cleansing, debridement of eschar or necrotic tissue, staging (see table opposite), and packing if there is crater formation. Packing should occlude the ulcer, but should be loose to avoid adding to the pressure damage. Dressings should keep the ulcer moist.

Staging of pressure sores

Stage 1	Skin intact with persistent redness due to pressure
Stage 2	Ulcer involving the epidermis or dermis.
Stage 3	Ulcer involving subcutaneous tissue layer. May be undermined.
Stage 4	Ulcer extends through the fascia to muscle, tendon, or bone. Undermining and tunnelling may be present.
Unstageable	Ulcer bed cannot be visualised due to slough or eschar