Management of wounds

1) Employ universal precautions:

• Gloves & Apron
• Goggles/face shield
• Safety with sharps

2) Initial Management:

• Achieve haemorrhage control by applying direct pressure with sterile orclean 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
• When controlled, assess distal to wound for vascular or neurological impairment
• If unable to control haemorrhage, transfer to the ED as soon as possible.

3) Wound cleaning:

• 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

4) Dressings

• 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

5) Check tetanus status

• 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

6) Advice to Patients

• Keep wounds clean and dry for the first few days
• Limb wounds require rest & elevation for the first 24 hours

7) Review of 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

8) Suture and time to removal

A guide to the time of removal is shown in the below table.

• 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.