Management of Cut and Lacerated open Wound (CLW)

INITIAL ASSESSMENT AND HEMOSTASIS:    

• Rule out life threatening conditions and ensure that the patient is vitally stable

• Do a local X-Ray (if indicated/for suspected injury) to rule out stone, soil, etc

• Upon presentation, a laceration should be evaluated, and the bleeding controlled using direct pressure or even ligation of bleeding vessels/ spurters (under local anesthesia), if needed. If it's an oozing wound/ bleeding copiously, use H2O2 and compress

DECONTAMINATION OF THE WOUND:    

• Thorough cleaning to be done, no dirt/blood should be left in the wound. Copious wound irrigation with normal saline with a 50 ml syringe and 18-gauge needle (sometimes done directly by punching a hole into the saline bottle and pressing it) which washes away foreign matter and dilutes the bacterial concentration to decrease post-repair infection

 

• Any visible foreign matter should be removed with forceps, and devitalized tissue removed with sharp debridement with scalpel or dissecting scissors to reduce the risk of infection

 

• Local anesthesia with lidocaine 1% is given (especially if suturing is required)

 

• After anesthetising the wound, clean again, more vigorously (as the patient will be more compliant now)

• Foreign bodies near blood vessels, nerves, and joints should be removed with caution, and referral to seniors should be considered

 

• Local hair should be clipped, not shaved, to prevent wound contamination   

    

REPAIR OF THE WOUND:       

1. For clean wound, small wound - suturing can be done:    

• Deep, multiple-layer wounds should be repaired using absorbable, simple interrupted sutures. Most other wounds can be closed effectively with non-absorbable, simple interrupted suture

  

• Absorbable sutures, such as Vicryl, Dexon and Monocryl are used to close deep, multiple-layer lacerations (Usually, 3-0 nylon (Ethilon) on cutting bodied needle is used)

• In general, a 1–0 or 2–0 suture is appropriate on the trunk, 3–0 or 4–0 on the extremities and scalp, and 4–0 or 5–0 on the face

• The horizontal mattress technique may be the best option for closing wounds on fragile skin because it spreads the tension along the wound edge

• The vertical mattress technique is good for closing high- tension wounds. It is also used to evert wound edges in areas that tend to invert, such as the posterior neck or concave skin surfaces

Place a latex drain in deep oozing wounds to prevent hematoma formation

 

 

        2. For clean contaminated wound or large wound where suturing is difficult:

 

• Perform wound debridement and wound toilet: 

I. Wound debridement - removing all dead and devitalised tissue from the wound

II. Wound toilet - Cleaning skin surrounding wound with antiseptic and irrigation of would with saline

These steps favor wound healing by secondary intention

• Continue the cycle of surgical debridement and saline irrigation until the wound is completely clean

• Pack wound lightly with damp saline gauze and cover the packed wound with a dry dressing

 

Change the packing and dressing daily or more often if the outer dressing becomes damp with blood or other body fluids.   

VIDEO LINK: https://youtu.be/bSQbgiy3KB0 

For suturing techniques and debridement, please refer to the respective documents. 

Written by our guest authors Omkar Doiphode and Tushar Mahajan
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