Provide effective analgesia or anesthesia based on wound severity, location, and other factors (See CPG 16 and Table 19).1-6

  1. Apply sterile water-soluble lubricant liberally to the wound bed and then clip the hair generously around the wound. Gently cleanse the skin around the wound, but not the wound bed, with surgical scrub. Gently lavage the lubricant and gross contaminants from the wound using sterile saline or lactated Ringer‘s solution (LRS); do not use tap water except in very grossly contaminated wounds with large amounts of debris, in which case it may be more expedient to flush the wound with warm water under gentle pressure initially. The goal of initial lavage is to remove gross contaminants and reduce the bacterial burden.
  2. Debride grossly necrotic tissues and non-viable tissue carefully using aseptic technique and sharp dissection. Do not mass ligate tissues or use cautery excessively, as this usually leads to necrosis of these tissues and serves as a bed for infection. Use caution not to damage, transect, or ligate major blood vessels (unless actively hemorrhaging) or nerves, as these are crucial to maintain effective blood flow and innervation distally.
  3. Lavage of the wound is necessary to remove particulate debris and reduce bacterial contamination – remember the adage, “The solution to pollution is dilution.”
    • There are several devices acceptable and available for adjunctive wound irrigation. Simple bulb irrigation and gravity irrigation have been the preferred method of wound irrigation. The bulb and syringe method has been more widely accepted and is significantly less expensive. Large bore gravity-run tubing has been favored for quick irrigations. Pulsatile jet lavage irrigation using a battery powered system is another method of adjunctive irrigation in the overall management of contaminated crushed wounds. It must be emphasized that all methods of wound irrigation, including pulsatile lavage, are adjuncts to sharp, surgical debridement and not a substitute for surgical debridement.
    • Normal saline, sterile water and potable tap water all have documented similar usefulness, efficacy and safety. Sterile isotonic solutions are readily available and remain the fluid of choice for irrigation. If unavailable, sterile water or potable tap water can be used.
    • Bacterial loads drop logarithmically with increasing volumes of 1, 3, 6, and 9 liters of irrigation. The current recommendations are as follows: 1-3 liters for small volume wounds, 4-8 liters for moderate wounds, and 9 or more liters for large wounds or wounds with evidence of heavy contamination.3
  4. Generally, contaminated and dirty/infected wounds should not be sutured until healthy granulation tissue is established, which generally occurs in 3-5 days. This is especially true for bite wounds.

 

Table 19.  Management of Open or Necrotic Wounds in MWDs

Table 19.  Management of Open or Necrotic Wounds in MWDs