Wounds

Overview

Definition

A wound is any injury causing an interruption of the normal continuity of affected structures or tissues, most often the skin. The skin, the outer integument, is the first line of defense against microorganisms; its loss facilitates entry of microorganisms into wounds. Wounds are classified as incised (made with a sharp object that creates a clean cut, such as bites, knives, scalpel), contused (made by a blunt object that may not break the skin but may cause significant damage, such as bumping the head when falling); lacerated (made by an object such as barbed wired that creates a jagged, irregular cut); puncture (made by a pointed object such as an ice pick or bullet), or thermal and chemical burns (made by scalds, fires, flammable liquids, gases, electricity, and chemicals), and decubitus ulcers (bed sores or diabetic ulcers).

Etiology

• Blunt or penetrating trauma
• Surgery
• Chemical injury
• Thermal injury
• Temperature extremes (e.g., burns, frostbite)
• Ionizing radiation
• Tissue breakdown due to malnutrition or diabetes

Risk Factors

• Age (e.g., elderly)
• Malnourishment, especially protein depletion
• Trace element deficiencies, especially zinc
• Vitamin deficiencies, especially vitamin C
• Compromised general health
• Location and severity of the wound
• Steroid use
• Radiation and chemotherapy
• Diabetes mellitus
• Smoking
• Weight loss or obesity

Signs and Symptoms

• Erythema
• Edema
• Pain and tenderness
• Heat
• Possible fever with infection
• Serous, sanguineous, serosanguineous, or purulent exudate
• Loss of function (or mobility)
• Foul smell (in infected wounds only)

Diagnosis

Physical Examination

A complete assessment, with a history of the insult event, is essential to determine the extent and severity of the injury, possible contamination, and conditions that might complicate the clinical course and treatment. Wound healing is often divided into three types: (1) first intention healing in which the edges of a wound are approximated and closed with sutures (e.g., laceration), thus scarring is usually minimal; (2) second intention healing in which the edges of a wound are not approximated and the wound is left open to granulate (e.g., burns, ulcers), thus scarring is often wide and deep; and (3) third intention healing in which a wound is left open initially because of contamination and then subsequently closed surgically. Astute clinical observation is essential to diagnose possible wound infection, particularly with human bites.

Laboratory Tests

• Complete blood count, to monitor leukocytosis (white blood count should stay between 5,000 and 10,000/mm³), which may herald the development of sepsis
• Urinalysis, blood urea nitrogen (BUN), and serum creatinine, to monitor renal function
• Wound cultures, to measure the number of bacteria (<105 organisms per gram of tissue)
• Sedimentation rate
• Electrolytes

Pathological Findings

There are generally four stages of wound healing: (1) vascular response (immediately for about 10 minutes) characterized by blood vessel constriction, smooth muscle contraction, platelet aggregation, blood coagulation, followed by vasodilation, processes that are mediated by histamine release; (2) inflammatory response (days 1 to 5) characterized by infiltration by neutrophils, monocytes, macrophages, and lymphocytes to protect against invasion by microorganisms; (3) proliferative phase (days 5 to 20, depending on the amount of necrotic material and infection) characterized by formation of granulation tissue, collagen synthesis, angiogenesis, and wound contraction, processes that are mediated by cytokines and growth factors; (4) maturation stage (day 20 to resolution, which could take months or years) characterized by remodeling of scar tissue, the basic component of which is collagen, a sturdy structural protein found throughout the body. Scar tissue is only 80% as strong as normal tissue.

Treatment Options

Treatment Strategy

Treatment depends on the type and severity of the wound. Some wounds are characterized by a loss of tissue, requiring grafting to repair, and others, including clean lacerations, result in no tissue loss. It is important to determine at the outset, based on the history and physical, whether or not the wound can be closed immediately either by suturing or grafting, or delayed because of contamination. A contaminated wound can be cleaned sufficiently so that it can be closed, but infected wounds are never closed until the infection has been successfully treated. Wounds must be protected from additional physical, chemical, or bacteriologic complications.

Drug Therapies

• Analgesics, for comfort especially before wound closure or dressing changes
• Antiseptics (e.g., povidone iodine), to clean contaminated wounds
• Systemic antibiotics for wound infections; broad-spectrum antibiotics for sepsis
• Amoxicillin/clavulanic acid (250 to 500 mg orally tid) or ampicillin/sulbactam (1.5 to 3.0 g intravenously every six hours) for animal bites (clindamycin or ciprofloxacin can be substituted for penicillin-allergic patients)
• Medicated dressings (e.g., gauze impregnated with topical antimicrobial agents such as silver sulfadiazine cream, mafenide cream, silver nitrate), to aid healing and make dressing changes less disruptive to epithelialization
• Triamcinolone (10 mg/mm³), to ameliorate hypertrophic scar formation (keloid)
• Tetanus immune globulin, for tetanus prophylaxis; penicillin (10 to 12 million units intravenously for 10 days); metronidazole (500 mg every 6 hours or 1 g every 12 hours) for tetanus infection
• Exogenous growth factors (e.g., epidermal growth factor [EGF], transforming growth factor-beta [TGF-beta], platelet-derived growth factor [PDGF]), to accelerate normal healing (experimental)

Surgical Procedures

• Surgical excision of burned tissue and wound debridement (removal of devitalized or contaminated tissue or foreign bodies)
• Skin grafting
• Excision and drainage, for wound abscesses
• Intubation or tracheostomy, for hypoventilation associated with severe tetanus or pneumonia associated with burn patients
• Splinting, to inhibit contraction, the movement of adjacent skin to close an open wound; in some parts of the body contraction can cause deformity and immobility

Complementary and Alternative Therapies

Homeopathic remedies may provide excellent relief of acute trauma. In addition, nutrients and herbs can help reduce inflammation, speed healing, and minimize the risk of secondary infection.

Nutrition

These supplements can also be taken before surgery to reduce healing time. Lower dose or discontinue when wound has healed.

• Beta-carotene (250,000 IU/day) or vitamin A (50,000 IU/day) promote healthy scar tissue. These are high doses and should not be taken for longer than one to two weeks without physician supervision. Reduce dose to 50,000 IU of beta-carotene and 15,000 to 25,000 IU of vitamin A daily after two weeks. Vitamin A should be avoided by women who are pregnant or trying to conceive.
• Vitamin C (500 to 1,000 mg tid) enhances tissue formation and strength.
• Vitamin E (400 to 800 IU/day) promotes healing when taken internally. May also be used externally once the acute phase has passed and new skin has formed. Higher doses may be beneficial for burn victims.
• Zinc (10 to 30 mg/day) stimulates wound healing.
• Bromelain (250 mg tid between meals) is a proteolytic enzyme and an anti-inflammatory that has been shown to reduce postsurgical swelling, bruising, healing time, and pain.
• Seacure (3 capsules bid to tid) is hydrolized whitefish protein that provides absorbable protein necessary for wound healing.

Herbs

Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or tinctures (alcohol extraction, unless otherwise noted). Dose for teas is 1 heaping tsp. herb/cup water steeped for 10 minutes (roots need 20 minutes).

• Turmeric (Curcuma longa) is an anti-inflammatory that potentiates bromelain. Use the dried extract 250 to 500 mg tid.
• Gotu kola (Centella asiatica) promotes connective tissue repair, supports normal wound healing, and prevents scar hypertrophy and keloid formation. For best results, use a standardized extract 60 mg one to two times daily. For tincture, take 60 drops tid to qid. Gotu kola may also be used topically as a wash for burns to minimize skin shrinking. Note: in some patients gotu kola can cause insomnia, agitation, or overstimulation of the sympathetic nervous system. Reduce dose accordingly.
• Coneflower (Echinacea purpurea) increases macrophage activity. Goldenseal (Hydrastis canadensis) is an antimicrobial that enhances healing. Use them together to protect against secondary infection. Equal parts of tincture may be taken 30 to 60 drops tid to qid.
• Powders of goldenseal, comfrey (Symphytum officinale), and marshmallow root (Althea officinalis) may be applied topically to enhance healing and minimize infection. Washes or compresses of cooled tea containing these herbs may also be used.
• St. John's wort (Hypericum perforatum) oil applied topically helps prevent postsurgical adhesions and may relieve nerve pain.
• Aloe vera gel applied to burns and wounds provides excellent pain relief and speeds healing.
• Marigold (Calendula officinalis) and plantain (Plantago major) aid in healing and can be used topically as salves or creams. These should only be used in incisional or "clean" wounds. Due to their fast action, they could encapsulate an infection.
• Granulated or confectioner's sugar applied topically to decubitus ulcers speeds wound healing. Safe for diabetic ulcers.

Homeopathy

Some of the most common acute remedies are listed below. Acute dose is three to five pellets of 12X to 30C every one to four hours until symptoms resolve.

• Arnica for bruised feeling and grief and/or shock from trauma
• Staphysagria for pain from laceration or surgical incisions
• Symphytum for wounds which penetrate to and involve bone
• Ledum for puncture wounds
• Urtica for burns
• Hypericum for injuries and trauma to nerves
• Keloid gel (Wala) for keloids

Patient Monitoring

Patients must be monitored for signs of bleeding, discoloration, or swelling in and around the wound. Fever, increasing pain, and the development of purulent drainage all indicate the presence of local infection and possible sepsis. Attention to nutritional status and positioning (to avoid undue pressure on the wound) are critical to healing.

Other Considerations

Prevention

Most wounds are accidental and often preventable. Wound infection and other complications can be prevented by careful aseptic technique and prophylactic antibiotics.

Complications/Sequelae

• Keloid scar tissue formation is an overgrowth of scar tissue that can be deforming. A keloid scar often returns even if excised.
• Wound contamination (10% if wounds), for example by Clostridia, Staphylococcus, Pseudomonas, Proteus, and Klebsiella, can occur in three stages: simple contamination, cellulitis, and myonecrosis (gas gangrene). Treatment consists of drainage, surgical debridement, and in severe cases, amputation. Fungal infections (e.g., Candida, Aspergillus) and herpes simplex can also compromise wound healing.
• Wound hemorrhage, usually a result of poor technique.
• Burn wound sepsis occurs when microorganisms invade subeschar tissue. Because most burn wounds are avascular, antibiotics do not adequately suppress microbial growth. Pneumonia is one of the most common infectious complications in burn patients.
• Tetanus (Clostridium tetani) occurs most often in mild penetrating injuries as a result of splinters, thorns, rusty nails, or dirty abrasions and lacerations, often because these mild injuries are ignored. Trismus (lockjaw) is pathognomonic. The mortality rates are as high as 30%, but for patients who recover, recovery is total. Human tetanus immune globulin (TIG) can prevent tetanus.

Prognosis

Prognosis is dependent on the extent and severity of the initial wound, as well as of any subsequent infection.

References

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