Management of wounds

Achieve haemorrhage control by applying direct pressure with sterile or clean dressing/gauze
If bleeding passes through the first dressing, apply another dressing on top. If bleeding continues DO NOT just apply a further dressing on top: remove, identify the bleeding point and properly apply ‘direct’ pressure onto it.
Elevate the wound if possible
If still bleeding, consider compressing an indirect pressure point proximally
If bleeding uncontrollable by other means, consider the use of haemostatic an arterial tourniquet for limb haemorrhage
When controlled, assess distal to wound for vascular or neurological impairment
If unable to control haemorrhage, transfer to the ED ASAP, ideally with IV access, the requirement for fluids guided by systolic blood pressure or loss of the radial pulse
Consider the administration of TXA for potentially life-threatening haemorrhage

Consent: players if possible should verbally, or in writing, consent to administration of local anaesthetic and closure of a wound
Safety:
- Be aware of the risk of allergic reactions
- Calculate the maximum dose allowed
Administration:
- Position the patient, ensuring the site of administration is supported and accessible
- Use a small needle (23 or 25 Gauge)
- Aspirate and check there is no blood in the syringe before injecting
- Inject slowly to reduce the pain and if resistance is felt, then stop
- Maintain a rapport with patient
- Document the time, site of injection, type and quantity of local anaesthetic used

Local infiltration anaesthesia
- Local anaesthetic is injected in the immediate vicinity of the wound
- Commonest technique
- Anaesthetic effect within 1-2 minutes
- Anaesthesia lasts 30-60 minutes
- Clean wounds – local can be injected in through the cut surface of the wound
Field blocks
- Infiltration of LA subcutaneously around the operative field
Nerve blocks
- Injecting LA around the relevant nerve for temporary control of pain e.g. digital nerve block

Saline (no proven benefit with Cetrimide or Chlorhexidine)
High-pressure irrigation can be achieved with an 18g needle on a 20ml syringe
Irrigation with a copious quantity of normal saline. “The solution to pollution is dilution”
If embedded debris, then scrub anaesthetised wound with scrubbing or clean tooth brush

Aims of wound closure:
- Anatomical and functional approximation of tissue with minimal risk of subsequent complications
When not to close:
- Wounds greater than 6 hours old
- Wounds that could be infected e.g. bites
- Wounds that need further exploration
- Stab wounds of neck, chest, abdomen and perineum
- Open fracture wounds
- Wounds over infected joints
- Most wounds needing neurovascular and/or tendon repair
- Wounds requiring specific expertise; eyelids/lips/intra-oral, fingers etc
- Wounds that have been crushed or have devitalised tissue and/or skin loss
- Send to ED covered in wet gauze
Techniques in closure (See appendix 1)
- Treat the tissues with respect.
- Beware of arterial bleeders
- Ensure that the sutures are not too tight
- Consider use of interrupted sutures, as tensile strength is greater
- Wound edges should be everted
- It may be necessary to close wounds in layers

Only use if necessary
Apply a dry non-adherent dressing that adequately covers the wound
Ensure wound is covered on all four sides
Review dressing after 48 hours or earlier if any signs of infection
Types of dressing: dry dressing, Vaseline gauze, antibacterial dressings etc.
Consider using a layer of Jelonet® or Inadine gauze® to prevent dressing sticking to the wound

If the player has had had all 5 immunisations (baby, preschool & ~14 years) and a relatively clean wound, they do not need to have further tetanus booster
If not had the full immunisation programme or higher risk e.g. dirty rugby pitch, then need booster or tetanus immunoglobulin depending on the level and type of contamination
Information on tetanus status can be found from the patient’s primary care provider, or a booster or course of antitetanus given in primary care or an Emergency Department

Not required for most wounds
Thorough cleaning and irrigation is the best way to prevent infection
Consider use of antibiotics for: Bites Penetrating injuries Wounds > 6 hours old Complex intra-oral wounds Heavily contaminated wounds Unable to clean adequately Underlying fractures e.g. fingertips Patients at risk (post-splenectomy)
Antibiotics of choice: Co-Amoxiclav Clarithromycin (for those with penicillin allergy).
Consider topical chloramphenicol 1% QDS for 5 days to facial wounds.

All wounds suspicious of developing infection should be reviewed within 48 hours
Patients should be advised to return earlier if developing any signs of infection

A guide to the possible choice of sutures and the time of removal is shown in the below table.

Part of the body	Suture & size	Time to removal
Scalp	2/0 or 3/0 absorbable, Non- absorbable	7 days
Trunk	3/0 non-absorbable	7-10 days
Limbs	4/0 non-absorbable	7-10 days
Hands	5/0 non-absorbable	7-10 days
Face	5/0 or 6/0 absorbable	3-5 days
Lips, tongue, mouth	5/0 or 6/0 absorbable
Over joint surfaces e.g. knee, elbows	3/0 non-absorbable	10-14 days

The time of removal shown is the optimal time recommended for wound healing and reducing the risk of infection. Fitting around supporting activities (training, matches) may result in sutures being left in situ longer e.g. the day after the next game. This requires careful monitoring and possibly the use of antibiotics if there are signs of infection.
Removal of sutures should be undertaken with a sterile pair of scissors or a bespoke ‘once only use’ stitch cutter after cleaning the healing wound. The suture should be cut where it enters the skin on one side and then pulled out to prevent any of the suture that was on top of the skin being pulled through the wound with the potential to introduce infection.
After removing sutures it is good practice to use adhesive strips e.g. steristrips ® to allow some support to the healing wound tissue for a few days after removing sutures. If at the time of removing sutures there is concern about dehiscence of the wound then a consideration may be removing alternative sutures for a period of time (filing the gaps with steristrips®) before removing all the sutures. If this technique is employed an assessment of potential infection should be made.