WOUND MANAGEMENT

5. SURGICAL CLASSIFICATION OF WOUND

5.1. Clean wounds: These include surgical wounds which are acquired under relatively sterile conditions and do not involve entry into the
• GI tract
• Respiratory and
• Urinary tracts

5.2 Clean contaminated wounds: These occur when the above tracts are opened under sterile conditions.
5.3 Contaminated wounds : Contaminated wounds are all wounds outside the O.T. i.e.
• Street, industrial and domestic accidents.
• War injuries would also fall into this category.

5.4. Infected wounds: Infected wounds are one of the above wounds which may present with signs of infection or are contaminated and left untreated for more than 6-8 hours.

6. MANAGEMENT OF WOUNDS

6.1 Primary wound closure: All clean, clean contaminated and contaminated wounds qualify for this treatment. However, the contaminated wounds presenting within six hours would require cleaning and debridement under sterile conditions and suturing. Antibiotics may need to be given for both clean contaminated and contaminated wounds.In most cases the wound will heal by primary intent. However:
Fig 1.6 a & b

• Inspect under good light for assessment of contamination injury to structures. Decide if decontamination and repair require local regional or general anaesthesia.
• Small wounds require local anaesthesia. In casualty theatere the wounds is cleaned with 1% cetrimide and irrigated with sterile saline.
• The devitalized tissue is removed the help of forceps and scalpel (debridment) The deep layers are repaired using catgut suture and skin edge with silk or nylon (primary suture)

6.2. Delayed primary suture: In contaminated wounds when doubt exists due to delay in presentation:
• The wound is cleaned with cetrimide 1% and H2O2 and debrided by removing the devitalised tissue and cutting the skin edges to get a linear scar.
• The wound is not sutured but dressed and if no infection is seen in 24-48 hours later the wound is sutured at that time.
• In cases of gross contamination and infections the wound is cleaned and debrided as before,but left open packed with gauge soaked in antiseptic. Antibiotics are given after frequent dressings for a few days, a DELAYED PRIMARY SUTURE can be performed for closure of wound.
Fig 1.7
6.3. Secondary suture: This method is suitable for those wounds that show infection. These are cleaned and dressed after removing dead tissue and the patient kept on appropriate antibiotics. When pink healthy granulation appears the skin edges can be freed from the granulation and sutured. This is referred to as healing by secondary intent by production of granulation tissue.

6.4 Skin grafting: In some wounds the skin loss may be large as in burns. Initial treatment is with regular dressings and on appearance of granulation, splits thickness skin graft is obtained from a healthy donor site of the patient and transferred to the wound site. The skin graft survives on top of the granulations and fills in the skin gap.

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