The LSUHSC New Orleans
Emergency Medicine Interest Group
The Student Procedure Manual
Wound Care and Dressings
by Gerald Falchook with
-Primarily closed wounds (lacerations)
-Partial thickness wounds
-Most commonly used dressings
- Postrepair wound care requires subsequent application of appropriate wound
dressings and assessment of possible tetanus prophylaxis.
- The application of dressings and further wound care is preceded by stabilization
of the patient, a medical history, and a physical examination. Some wounds will
require imaging techniques to detect injury to bone or the presence of foreign
bodies. Appropriate wound closure and application of topical antibiotics also
precede the use of dressings.
- Various dressing materials are available, and several factors should be taken
into account when choosing the appropriate dressing. There are eight types of
absorbent cotton gauze, each type defined by the number of warp and woof threads
per square inch.
- The functions of the dressing include:
- Absorption of wound exudates
- Debridement of open wounds
- Providing a protective barrier against exogenous bacteria
- Exertion of pressure on underlying tissues.
- The optimum dressing should have a nonadherent surface, be permeable to gases,
and have a capacity to absorb some fluid without inducing desiccation of the
wound. The outer barrier should be impermeable to bacteria and other particulate
matter but permeable to water vapor.
- A drying wound produces a thick, hardened scab that impedes the process of epithelialization.
Excess fluid can lead to maceration of tissue and may be a potential culture
medium for bacterial proliferation. Gaseous permeability is essential because
epithelialization is greatly accelerated in the presence of oxygen.
Primarily closed wounds (lacerations):
- With the exception of wounds located on the face, primarily closed wounds are
covered by nonwoven microporous polypropylene dressings, which are attached
to surrounding skin by wide strips of microporous tape with no reinforcing fibers
(aka "paper tape"). In facial lacerations, the development of blood
clots between the edges of sutured wounds is of greater concern than the danger
of surface contamination. These clots are replaced by a healing scar that can
be avoided by swabbing the wound with half-strength hydrogen peroxide, or saline
every 6 hours, until the wound edges are free of blood.
Partial thickness wounds:
- Vapor permeable membranes are indicated for partial thickness wounds such as
abrasions, bums, road rash, and ulcers. Wounds treated with vapor-permeable
membranes fill with granulation tissue before reepithelialization of the defect.
- Use of hydrogen peroxide causes abraded skin to develop a scab that makes suture
removal tedious and painful to the patient. Instead, the skin abrasion wounds
and their edges should be swabbed with a water-soluble base, such as polyethylene
glycol with mupirocin (Bactroban), that disrupts the wound exudates, encouraging
their exodus from the wound. Permanent hyperpigmentation of abraded skin will
develop unless photoprotection is utilized with a sun-blocking agent for at
least 6 months following the injury.
***In all cases, it is important to keep the wound clean and dry during
the first 24-48 hours following application of the dressing.
Most commonly used dressings:
- Sterile 4x4s (aka "fluffs")
- Packing (a tape dressing, stored in a bottle; => pack it into the wound with
- Abdominal pads (aka "ABD" pads; these are BIG)
- In addition to protecting the wound as described previously, it should be cleaned
daily to remove crust formations. Daily swabbing with half strength hydrogen
peroxide or saline rids the wound of debris and blood clots that form between
sutured edges. Hydrogen peroxide should not be used after separation of the
scab because it is toxic to the epithelium and may produce bullae. It is safe
to bathe and get the wound wet 24 hours after the injury.
- Injured extremities should be elevated during the first 24-48 hours following
injury. Elevation lessens edema, hastens healing, and mollifies pain.
- Table 1 lists guidelines for identifying tetanus -prone wounds. However,
the immunization status of all patients must be considered, regardless of
severity of the wound. The usual incubation period of tetanus is 7 to 21 days
but ranges from 3 to 56 days. Immunization should be given as soon as possible
but can be given days or weeks after the injury. The dose of tetanus toxoid
is 0.5 ml IM, regardless of the patient's age. Diptheria vaccination (dT)
should be given along with tetanus toxoid. The dose of tetanus immune globin
(TIG) is 250 units in patients 10 years old or older, 125 units in children
ages 5 to 10, and 75 units in children under the age of five. A single injection
of TIG provides protective levels of passive antibodies for at least four
weeks. Tetanus toxoid and TIG may be administered during the same visit but
should be injected with separate syringes at different sites. The application
of Diptheria and tetanus toxoids is contraindicated by a history of neurologic
reaction or a severe hypersensitivity reaction after a previous dose. Local
side effects such as erythema and induration without tenderness do not preclude
continued use. Severe Arthus-type hypersensitivity reactions to dT are indicated
by high serum tetanus toxin levels. Patients with contraindications to tetanus
toxoid but who have not completed primary immunization to dT and who have
tetanus-prone wounds should be given passive immunization with TIG.
Table 1: Tetanus-Prone Status Identification
|Age of Wound
||> 6 hours
||< 6 hours
|Mechanism of injury
||Missile, crush, bum, frostbite
||Missile, crush, bum,
|Signs of Infection
|Contaminants (dirt, feces, soil, saliva)
|Denervated and/or ischemic tissue
- The patient should be educated to identify the signs of wound infection and
to distinguish signs of infection from the normal inflammatory response of the
injury. Infection is indicated by redness, swelling, increased pain, fever,
pus, or red lines progressing up an extremity. Injuries classified as high risk
must be reexamined for infection 48 hours after the trauma regardless of its
- Allergies to tapes and antibiotic creams
- Hematoma formation as a result of excessive
- Cutaneous nerve damage
- Laceration wounds will seal themselves within 24 hours and will not require
additional dressings. Most other wounds require a follow-up inspection by the
physician or department that initially treated the wound. Follow-up intervals
vary according to the severity of the wound (consult a resident).
- Hydrogen peroxide causes sutures to lose their color, and so decolorized suture indicates that
the patient has complied with the recommended postoperative wound care regimen.
- Emergency medicine: concepts and clinical practice. 4t' ed. Eds. Peter Rosen,
Roger Barkin. Mosby-Year Books, Inc.: St. Louis, 1998.
- Emergency medicine: a comprehensive study guide/ American College of Emergency
Physicians. 411 ed. Ed. Judith E. Tintinalli. McGraw Hill: New York,
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