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Caring for traumatic wounds in primary care

Una Adderley
RGN DN BSc BA
Research Nurse
Centre for Evidence Based Nursing
Department of Health Studies
University of York

District Nurse Scarborough and NE Yorks NHS Trust

E:una@adderleyspringfarm.fsnet.co.uk

Wounds caused by trauma place two main demands on the primary care clinician. Assessment skills and knowledge are needed to decide whether the patient can be appropriately treated within the primary care setting or should be referred for specialist secondary care. If the patient can be appropriately managed within primary care, the clinician needs to be familiar with the evidence base relating to that particular type of traumatic wound. Sometimes clear, evidence-based guidelines are available to guide clinical decision-making, but for some conditions no evidence base exists. The community clinician's skill then lies in identifying a reasonable treatment approach in the absence of research evidence.

Mechanical injuries
Most mechanical injuries are caused by nonsterile objects. The first principle of care is to discover the nature and cause of the injury. If a wound is contaminated by debris or dirt then thorough cleansing is required to minimise the risk of infection and avoid the risk of tattooing. Sometimes this means vigorous scrubbing, and it may be necessary to request an X-ray to ensure that no foreign bodies remain within the wound.
Tetanus inoculation may be required, and it may be appropriate to consider whether prophylactic antibiotics should be given. A systematic review of antibiotic prophylaxis found limited evidence from one trial that prophylactic antibiotics reduce the risk of infection after human bites, but confirmatory research is needed.(1) No evidence was found to indicate that prophylactic antibiotics are effective for cat or dog bites. There was limited evidence that prophylactic antibiotics after bites of the hand reduce infection but more research is needed.
For mechanical injuries requiring suturing, a systematic review found evidence that, for repairing simple traumatic lacerations, tissue adhesives are an acceptable alternative to standard wound closure.(2) The review found no significant difference in cosmetic outcome, and tissue adhesives took less time and caused less pain. However, there was a slightly higher risk of dehiscence.
When choosing dressings, the aim should be to protect but not to overtreat. Simple nonadherent dressings will often prove sufficient. Most acute wounds will heal spontaneously with little intervention, provided infection does not occur. Lower leg injuries in the elderly, such as pretibial lacerations, may benefit from mild compression (provided the limb does not suffer from arterial insufficiency) to promote venous return.

Burns
There are approximately 250,000 cases of burns a year, according to the National Burn Care Review.(3) This review was instigated and commissioned by the British Burns Association in response to concerns about the state of the UK burns service. One recommendation arising from the report was the need for uniform national clinical management and referral guidelines.
Burns can arise from heat, chemicals, electricity and radiation. Although the patient may be in obvious need of immediate referral to a specialist burns unit, good first-aid knowledge can alleviate suffering and lessen damage. However, the type of first aid will vary ­according to the cause of the burn.
Wet and dry heat, such as scalding from steam, boiling water or hot oil, or burning from a flame or hot objects are probably the most common types of burns (see Figure 1). The wound should be cooled by applying cold water as soon as possible for at least 10 but no longer than 20 minutes to minimise the risk of hypothermia.(4) Clothing should be removed unless it is sticking to the wound.

[[NIP10_fig1_69]]

Chemical burns caused by exposure to acids or alkalis should also be treated with prompt, prolonged copious irrigation with water and removal of clothing (see Figure 2). Cement and bitumen are both more common forms of chemical burns, and bitumen can be gradually softened using oil.

[[NIP10_fig2_70]]

Electrical burns arise from exposure to both low and high voltage and usually have two burn sites, from where the electricity entered and exited, as well as possible internal damage from the path of the electricity. An electrical burn may appear minor but conceal considerable internal damage.
Radiation is another form of burn, either from ­overexposure to the sun or as a side-effect of radiation treatment. Radiation wounds can appear years after the initial exposure. Again, cooling with water can be an effective first-aid measure.
Most "minor" burns can be appropriately treated within primary care. However, it is vital that all burns are assessed correctly to comprehend fully both the extent of damage at the site of the burn and its impact on the patient's general condition. Only then is it possible to make an informed decision about whether the patient requires referral for specialist treatment. In other words, although the treatment for minor and major burns may differ, the quality of assessment should be to the same high level to ensure that major burns are not misdiagnosed as minor.
The National Burn Injury Referral Guidelines detail the criteria to be considered for assessment (see Figure 3). Burn area is calculated according to the percentage of body area affected. The palmar surface area of the patient's own hand (wrist crease to fingertips) measures approximately 1% of the patient's total body surface area (TBSA).

[[NIP10_fig3_70]]

While complex burns should be immediately referred to a specialist unit, simple burns can be treated within primary care. The aims of treatment should be to protect the lesion from mechanical damage and infection, thus providing a safe environment for ­spontaneous healing to take place.
Burns injuries damage the blood vessels in the immediate surrounding area, thus restricting or even stopping the flow of blood in the surrounding area. This compromised circulation may cause further damage to the burn lesion.
The majority of burns that can be appropriately treated in primary care will involve the destruction of the epidermis only. There may be blister formation and pain (see Figure 4). At the time of writing, no systematic review could be found on the treatment of burns lesions. There is considerable debate over whether blisters should be left intact to encourage faster epithelialisation, reduce pain and minimise the risk of infection.(5) Conversely, there is concern that leaving blisters intact increases the risk of sepsis and prevents accurate assessment by concealing the base of the wound.

[[NIP10_fig4_72]]

Assuming the burns lesion is open, there is likely to be copious exudate. Cleansing using a warmed, sterile isotonic cleansing solution such as saline 0.9% will remove stale exudate. Nonviable tissue should be debrided either mechanically or through autolysis as it will be a focus for infection. The antimicrobial, silver sulphadiazine, is a traditional choice to minimise the risk of infection but will require careful cleansing to enable inspection of the wound bed for ongoing assessment of healing. Antitetanus inoculation may also need to be considered.
Dressing choice can be challenging. The aim is to maintain hydration while preventing maceration and to allow the maximum range of movement over flexure joints. The choice of dressing should allow for maximum wear time to minimise the risk of infection, cooling and pain associated with dressing change. Tulle-gras has been a traditional choice but is prone to drying out. Foam dressings can contain copious exudate, and silicone dressings are low-adherent and allow movement. Hydrocolloids and films protect against infection but may not cope with copious exudate. Once epithelialised, emollients will minimise dryness, and the patient should avoid exposing the afflicted area to the sun.

[[NIP10_pp_72]]

References

  1. Medeirois I, Saconato H. Antibiotic prophylaxis for mammalian bites (Cochrane Review). In: The Cochrane Library. Issue 1. Oxford: Update Software; 2003.
  2. Farion K, Osmond MH, Hartling L, et al. Tissue adhesives for traumatic lacerations in children and adults (Cochrane Review) In: The Cochrane Library. Issue 1. Oxford: Update Software; 2003.
  3. British Burns Association. National Burn Care Review. 2001. Available from URL: http://www.baps.co.uk/documents/nbcr.pdf
  4. Atkinson A. Treating minor burns. J Commun Nurs 1998;12:18-25.
  5. Flanagan M. Should burn blisters be left intact or debrided? J Wound Care 2001;10(1):31-45.

Resources
National Burn Care Review
Available at W:www.baps.co.uk/documents/nbcr.pdf

Cochrane Library of Systematic Reviews
W:www.cochrane.org