Dressings

Goal: Quality dressing application focuses on keeping wounds clean, absorbing drainage, debriding fibrinous exudate from the wound surface, and increasing the speed of healing.

Shallow Wounds or Abrasions

Best: dressing tailored to the specific type of wound Abrasions: Apply antibiotic ointment (e.g., Bacitracin or Silvadene) to the skin, place a non-adherent dressing over the area (e.g., Adaptic [KCI, http://www.acelity.com] or Telfa [Medtronic, http://www.medtronic.com]), and cover with an absorbent gauze dressing (e.g., Kerlix [Medtronic]). This should be repeated daily.

- Alternative: Silverlon (Argentum Medical, http://www.silverlon.com) can be applied directly to a clean wound and covered with a gauze dressing. Moisten outer gauze dressing with water or normal saline daily. Replace Silverlon every 3–5 days (can remove and clean with water and reuse for up to 5 days). The outer gauze can be changed as needed if it becomes saturated with exudate or otherwise dirty. If the patient develops any evidence of infection, the Silverlon must be removed and the wound inspected sooner than 3–5 days.
- Puncture wounds or small open wounds: Apply an absorbent gauze dressing over the area and change as needed when it becomes saturated with exudate or otherwise dirty, or at least once every 24 hours.
- Small, clean lacerations: may be sutured, or Dermabond (Johnson & Johnson, http://www.ethicon.com) can be applied to the skin to adhere the wound edges together. Ensure that the Dermabond is applied to the skin, not to the deeper tissues. If Dermabond is used to close the wound, this will also suffice as a dressing.

Better: Apply any available sterile gauze dressing.

Minimum: Apply any available clean dressing.

Deep or Large Open Wounds

Best: Negative pressure wound therapy (NPWT)

- Commercially available kits such as the KCI Wound vacuum-assisted closure (V.A.C. Therapy, KCI, http://www.kci-medical.com) device can be used to both cover the wound and promote wound healing.13 For exposed soft tissue, the pressure is usually set at 75–125mmHg of continuous suction.
- Field-expedient wound VAC devices can be improvised from gauze, Tegaderm or Ioban, and suction tubing hooked up to a suction device (Appendix D).
- NPWT dressings are generally changed every 2–3 days. Although they can be left in place for a longer time, the degree of granulation that can occur after 3 days generally leads to some bleeding with their removal.
- NPWT dressings placed over infected wounds should be changed daily, along with wound debridement and irrigation, until the infection is controlled.

Better: Wet-to-dry dressing

- Wet-to-dry dressings can be created using either a sterile isotonic fluid or clean water, if there is no sterile fluid available. A gauze dressing should be moistened (not soaked) and applied to all open, exposed tissues and loosely packed into the wound cavities. An absorbent gauze dressing or Army Battle Dressing pad is placed over top to absorb any extra fluids or exudate. This may be secured with tape or wrapped with a gauze bandage roll or elastic bandage.
- Removal of dressings from a wound provides its own form of mechanical debridement; exudate adheres to the bandages and is then pulled from the wound during changing. Inspect old bandages during a dressing change for signs of infection by observing the color and odor of the exudate; the color should be off-white or slightly yellow, and the bandage should not smell sweet or foul. Do not moisten the gauze being removed to make the dressing change easier, otherwise the debridement effect will be lost.
- Ideally, the dressing should be changed one or two times per day, unless the situation dictates a less frequent approach.
- For wounds that are already draining heavily, a dry-to-wet dressing may be used instead.

Minimum:

- Place a bulky dressing with dry gauze, absorbent padding, and elastic bandage; leave in place 4–7 days if wound is clean and without sign of infection. See Appendix A for further details on the ICRC method of wound care.