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Wild Iris Medical Education is an approved provider for paramedic and EMT continuing education in California by the Coastal Valleys EMS Agency: CE Provider #49-0057. Skin varies in thickness from less than one millimeter in the eyelids to greater than four millimeters on the soles of the feet, but everywhere, skin is composed of two layers, the epidermis and the dermis, underlain by a sheet of subcutaneous tissue (Habif, 2010). The skin has two layers, the epidermis and the dermis, below which lies subcutaneous tissue. There are no blood vessels in the epidermis, and it receives its oxygen and nutrients by diffusion from blood circulating in the underlying dermis. During normal healing, the epidermis re-grows from germinative cells left in the skin at the edges of the wound. Partial-thickness wounds, such as deep abrasions, destroy or remove the epidermis and may also destroy part of the upper portion of the dermis.
The tissue of the dermis contains small blood vessels, lymph vessels, nerves with their endings, and the smooth muscle fibers of hair follicles. Beneath the subcutaneous tissue layer, structures (such as muscles and organs) are enclosed in their own separate connective tissue sheaths. Ulcers can be made by innate destructive processes, but most ulcers are caused by external forces such as pressure, shearing, friction, and moisture.
Scars are imperfect replacements for damaged tissue, but scars are a natural result of healthy healing. At the other end of the spectrum, the wound patching process may go overboard and generate too many new cells or, more commonly, too much collagen in the scar. A contracture is a permanent fixture of the skin, and it cannot be repaired by stretching, massaging, or applying ointments, lotions, or creams. The stages in both these systems are overlapping and constitute what is also known as the cascade of healing. In a small clean wound such as a surgical incision, most of the healing processes are quick and take only a few days.
The first set of events in wound healing is the reaction phase, which corresponds to the hemostasis and inflammatory phases. This phase begins immediately after an injury, as blood vessels temporarily constrict and blood clotting begins.
Under healthy conditions, most of the new cells entering the wound after day 2 are mononuclear cells (monocytes), which are the second wave of white blood cells to migrate into a wound.
If the granulation tissue is covered with a dry, scabby exudate, the epithelial cells migrate slowly under the scabby exudate, including any remaining blood clots that form the scab, becoming dark colored and rough textured. When the wound area is not too large, epithelial cells repopulate the entire surface and generate a new epidermal covering; this process is called re-epithelialization. Underneath the growing epithelial layer, the granulation tissue is thickening and solidifying.
In a healthy wound, fibroblasts begin to fill the wound during days 2 to 4 after an injury.
As a wound heals, a special class of cells, the myofibroblasts, begins to pull the edges of the wound toward one another. Large wounds and wounds in which much tissue has been lost heal slowly and produce larger scars. Within hours of an injury, neutrophils and macrophages migrate into the wound and begin removing debris.
This sutured laceration (on the knee) may be a normally healing wound still in the inflammatory phase of healing, or it may be the beginning of a wound infection.
Operationally, the dirtier the wound, the more it must be rigorously cleansed to avoid infection. Antibiotic resistant strains of bacteria are a growing problem in dealing with infected wounds.
During normal healing, the granulation tissue develops a temporary dense capillary bed to provide sufficient fluid, nutrients, and oxygen to the growing cells.
Ischemia of a wound can arise from too much physical tension across the wound, ineffective oxygenation of the blood (anemia, lung problems, smoking), or reduced circulation (atherosclerosis, heart failure, kidney failure, vasoconstriction, too much pressure on the wound). Skin tension is negligible along skin creases, moderate over relaxed joints and muscles, and high over bent joints (knees and elbows) and over the skull.
Malnourished people begin to break down their proteins as a source of energy, and this slows healing. Patients who smoke have poor wound healing in addition to suffering a number of other skin problems (wrinkling, premature skin aging, higher risks of squamous cell carcinoma, psoriasis, and hair loss [Cao et al., 2011]).
Patients who are dehydrated may have impaired kidney functions and reduced blood volume, leading to decreased blood pressure and perfusion, which can slow wound healing. Another problem in wound closure is the use of suture material that is too thin and subsequently breaks. Finally, if sutures, staples, or tapes are removed too early, the wound edges will not have developed sufficient adhesion, and the wound will reopen. Staff and others entering an isolation room should always follow posted signs indicating the type of isolation and implement the appropriate additional protective measures. In hospitals, clinics, and medical offices, staff must use specially marked hazardous waste bags and disposal cans for any items grossly contaminated with bodily fluids. There may be differences between federal and state occupational health regulations regarding blood and other infectious material (BOIM) protocols for employees, nurses assistants, nurses, occupational therapists, physical therapists, etc.
Precautions and written protocols are for the protection of all caregivers and all patients.
Healthcare workers who will have contact with patients should be screened for infectious diseases (such as tuberculosis) when they are hired, and care should be taken to prevent bringing newly acquired infectious diseases to the workplace or on home visits. Primary wound care means acute wound care—managing a wound the first time it is presented to a healthcare professional. The procedures of modern wound care in proper order are: inspect, cleanse, close, and cover. The physician (or the RN, nurse practitioner [NP], or physician’s assistant [PA] if protocols provide) inspects the wound, estimating its depth, the degree of contamination, and the internal tissues that are injured, if any. For wounds on the extremities, an inflated blood pressure cuff or a purpose-made surgical tourniquet may be used as a controllable tourniquet proximal to the wound. Prepare the wound field by cleansing the area surrounding the wound, beginning at the center and working outward to avoid introducing additional contamination, clipping any interfering hair, and washing all the adjacent regions with an antiseptic solution. Using a purpose-made wound irrigation system, which pumps large volumes of fluid at a practitioner-selected pressure, and collecting it as above.
Scrubbing a wound by hand is called mechanical scrubbing or mechanical nonspecific debridement.
After washing the wound, gently pat it dry with sterile gauze, beginning at the center of the wound and working outward, and then wipe the skin around the edges.
Primary wound closure (by suturing, stapling, gluing, or taping) is also called healing by primary intention or immediate direct closure. Delayed primary closure lets the wound remain open initially and later closes it with sutures or staples. Choosing among the three closure plans is a balance between protection, risk of infection, and size of the eventual scar.
On the other hand, immediate primary closure of an unclean wound encourages the development of infection. While managing an open wound, the option of closing the wound directly during the first five days still exists. If the wound is complex, large, chronic, or highly contaminated, wound closure may be delayed by packing the wound with saline-moistened sterile gauze. In wounds with exposed or injured internal structures, such as nerves, joints, or bones, a surgical specialist is consulted before a decision is reached on a closure plan.
Depending on the severity of the infection, the patient may be discharged on either oral or intravenous (IV) antibiotics.
The wound should be evaluated professionally in 3 to 4 days, which is approximately the time when the healing process in an open wound is making the transition from the late reaction (inflammatory) phase to the regrowth (proliferative) phase.
The delay will have allowed time for nonviable tissue to become apparent, and the physician should debride and irrigate the wound again before closing it. Even though the bleeding may have stopped earlier, subsequent debridement and cleansing may restart it; therefore, before directly closing a wound, the physician will make certain that all bleeding is stopped.
For closing a wound, current options include sutures, staples, tape, and adhesives, or a combination of any of these. Suturing is probably the most widely used direct closure technique, but stapling has become increasingly popular, especially for surgical incisions. For small, superficial wounds such as minor skin tears, tape or purpose-made skin closures are often better than staples or sutures.
When the adjacent skin is clean and dry, increase its adhesiveness by painting tincture of benzoin on the skin or applying skin protectants alongside the wound.
For skin tears, place strips perpendicular to the edge of the skin flap to hold it as closely as possible its original, intact position. Glued wounds need extra care: they cannot be immersed in water and they can only be rubbed gently. Tissue glues slough off spontaneously after about 4 days, by which time the wound has usually healed sufficiently to remain sealed without the glue.
After the wound is closed, the surface is gently cleansed with moistened sterile gauze and the wound is covered with a sterile dressing and a protective bandage.
For skin tears, a colloidal water-based gel, such as Hydrogel, may be used to augment or replace a missing or incomplete skin flap. When choosing, tailor the primary dressing to the amount of drainage expected from the wound. There are frequent changes in the many different companies’ dressings, names, and types, and so it is important to gather up-to-date information on dressing options before selecting a particular dressing. Consider securing dressings with a gauze roll rather than tape if the patient’s skin is fragile due to age or coexisting diseases such as diabetes or vascular impairment.
In general, changing a dressing daily allows for assessment of the condition of the wound and progress of the healing process. Repeatedly moving a wound by contracting nearby muscles will slow wound healing and increase the size of the eventual scar, so any nontrivial wound that is in a part of the body near a joint may be immobilized. Tetanus prophylaxis, rabies prophylaxis, or systemic antibiotics may be ordered in some circumstances. Rabies is most common in bats, raccoons, and skunks, and the disease is transmitted in saliva. Unprovoked animal bites are more likely to develop rabies than bites from animals biting because they were disturbed or frightened. Rabies can be transmitted without the animal biting the person if the saliva gets into existing cuts or abrasions.
The decision to begin rabies prophylaxis depends mainly on the type of animal that caused the bite.
Rabies prophylaxis can be begun after the wound has been cared for, so there is time to consult and to make a well-informed decision. People who may have been infected with rabies virus need both active and passive immunization. Although systemic antibiotics are often given to patients with acute wounds, most clinicians argue that antibiotics should only be given with a specific purpose in mind.
Systemic antibiotics are best given as early as possible during wound treatment, and the first dose should be administered intravenously or intramuscularly.
For minimizing the risk of infection, systemic antibiotics cannot replace debridement and irrigation. The basic wound care techniques detailed above need to be tailored to the particulars of each individual wound.
To be considered a minor burn, the area injured must be a single small patch of the body outside of the hands, face, feet, armpits, popliteal region, or perineum.
Infants, older adults, and patients with major medical problems may need to be hospitalized for burns that would otherwise seem minor. Second-degree burns are called partial-thickness burns because they involve injury to the epidermis and part of the dermis.
Partial-thickness burns look red, white, or pink, and they tend to be wet, painful, and blistering. Full-thickness burns look grey, white, or brownish, and they tend to be dry, painless, and without blisters. In second-degree burn wounds, collapsed burn blisters can turn into protected areas in which bacteria can grow, causing an infection. As always, any mechanical or surgical debridement is done by physicians or specially trained nurses and physical therapists according to facility protocols.
Aseptic technique should be followed at all times due to the susceptibility of burns to infection. You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity. Hair, nails, sweat glands, and sebaceous glands are sunken epidermal appendages that lie in deep valleys in the dermis surrounded by a row of germinative epidermal cells.
The growing cells are called epithelial cells, and the regrowth of the epidermis is called re-epithelialization. In epidermal wounds, a new epidermis grows from the germinative cells that surround the bottoms of epidermal appendages deep in the dermis. Islands of less depth within the wound bed may generate epithelial cell growth, but usually epithelial cells migrate from wound edges toward the middle of the wound.
The dermis is also populated by a variety of individual cells including macrophages, fibroblasts (which synthesize the extracellular connective tissue components such as collagen to form a matrix that is the foundation for a scar), and mast cells (which release histamine and other molecules that increase inflammation).
The subcutaneous layer is held together by a continuous sheet of fibrous membrane that runs parallel to the surface of the skin.
When skin wounds extend deeper than the dermis, dirt is easily pushed into and spread within the subcutaneous tissue.
There are seven basic wound types: abrasions, lacerations, crushes or contusions, punctures, avulsions, burns, and ulcers.

Mild abrasions remove epidermis; serious abrasions also remove the dermis and, sometimes, subcutaneous tissue. A crush wound bruises and damages the skin and the underlying tissue, although the skin can remain closed in some crush wounds. Large wounds, wounds that heal slowly, and wounds involving extensive destruction of the surrounding tissues heal with large scars; nonetheless, these scars are not necessarily abnormal. Even under the best healing conditions, some normal scars may end up interfering with the movement of the skin and the underlying tissue.
This overactive scar-making process is usually triggered by a prolonged regrowth (proliferative) phase during healing. Keloids, however, are benign tumors, and the tendency to develop keloids is inherited, patients with darkly pigmented skin being particularly susceptible (Wolfram et al., 2009). Enlarged scars, however, sometimes contract excessively, becoming disabling or disfiguring ridges of connective tissue called contractures (Kamolz et al., 2009). In this phase, blood clots seal the wound, creating hemostasis, while a normal inflammatory reaction begins to remove bits of dirt and debris.
Soon, the local capillaries become excessively permeable, fluid flows out, and the tissues swell, producing edema. The various biologically active molecules being released into the wound also hypersensitize the endings of local pain nerves, causing them to react to smaller amounts of chemical and mechanical irritation and thus making the wound site tender.
Deep or large wounds, such as ulcerative pressure sores or burns, do not seal during this phase.
If the wound does not become colonized with bacteria, neutrophils stop entering the wound by about day 2 following the injury.
In this phase, new cells grow into the wound and begin to lay down the collagen and other extracellular fibers that will give strength to the scar. Eventually, these epithelial cells form the new epidermis and loosen the scab, which will crumble off the top of the scar. Over the next few days, the new epithelium continues to deepen and differentiate, and eventually, it becomes a typical epidermal layer. Within 48 hours after the injury, fibroblasts are filling the granulation tissue and laying down collagen and elastin fibers. In this phase, the number of fibroblasts in the new scar decreases and the temporary dense capillary network thins. The contraction is not only a surface phenomenon; the whole thickness of the wound edge is gradually pulled toward the center of the wound.
Its strength increases markedly over the next month as new collagen is laid down and then cross-linked. Wounds that have been contaminated with significant numbers of bacteria and other foreign material are at risk for developing infections because such wounds are not easily cleansed by the natural scavenging processes of the reaction (inflammatory) phase of healing.
It is not always easy to recognize an infected wound in the early stages: to the untrained eye, normal healing can look like a pathologic process. Differences in the available blood supplies account, in part, for the fact that facial wounds tend to heal better than foot wounds. Most skin in the body is being stretched, at least slightly, by the adjacent skin and the underlying structures, but the actual tension at any one location varies along the surface of the body. During a cutting, ripping, or puncturing injury, the tension from the adjacent intact skin pulls the free edges of the wound apart. The drawing also indicates the areas of the body where skin wounds have the highest risk of infection.
Diabetic patients lose sensation in their fingers and toes, so diabetic injuries tend to go unnoticed in the extremities. In older people, scars form with less and poorer-quality collagen, and older adults are more likely than the young to have wounds that reopen or dehisce (Reddy, 2008). Smoking causes vascular constriction, which decreases circulation and leads to chronic wounds. In the course of managing a wound, we reduce the amount of contamination, minimize the area that must be filled by new tissue, keep the granulation tissue moist, and protect the healing area. In an attempt to close wounds quickly, doctors sometimes suture together insufficiently cleansed tissues. Sutures that are too thin or that are tied too tightly can also tear through the weakened skin at the edges of the wound.
Although early studies showed statistically faster healing rates when Neosporin ointment was used, bacitracin is more commonly used as an antibiotic ointment due to sensitivities to Neosporin. In wounds, the regrowing epithelium, the newly growing blood vessels, and the fibroblasts that form new connective tissue are likely to be damaged by a large dose of ionizing radiation.
Disposable isolation gowns are worn with gloves for contact isolation, and masks are added for droplet isolation as well as for reverse isolation to protect patients with decreased immunity. Such regulations may also be optional for physicians and others who are considered independent contractors.
It is important to learn and remain up to date on such facility protocols and governmental regulations pertaining to these precautions.
They should be up to date on their immunizations; this includes vaccination against measles, rubella, varicella, hepatitis B, and ongoing yearly influenza immunizations.
Resistant strains of bacteria such as multidrug-resistant tuberculosis (MDRTb), MRSA (methicillin-resistant Staphylococcus aureus), and VRE (vancomycin-resistant Escherichia coli) are common in the general population. Gloves need to be removed properly away from the patient so any infectious material that becomes airborne does not reinfect the patient.
These wounds may have been too big, have involved too great a loss of blood, or have became infected. These are issues related to airway, breathing, and circulation—the ABCs of life support. The order in which they are to be treated is planned and prioritized, usually by the physician.
When it is time to treat an external wound, a history is taken, including the cause of the wound and a description of the environment in which it occurred. When there are injuries to internal structures (nerves, tendons, bones, muscles, ducts, organs), a surgical specialist is called in by the physician.
Caring for a wound will cause the patient pain; nevertheless, before an anesthetic is given, major nerves or blood vessels are checked for injuries. If there is a possibility that metallic contaminants or pieces of broken bone have been missed, the wound may be imaged to search for debris. It should only be performed by trained physicians, RNs, or PTs and in accordance with facility protocols. Making an evidence-based choice on whether to close the wound, and if so, how to close it, can minimize the risk of infection. The immediate primary closure of a well-cleansed wound protects it from new contamination and allows the most control over the size and appearance of the final scar.
Besides providing a protected environment for bacteria, wounds closed with sutures add new foci for infection, namely, the suture holes, the sutures themselves, and the tissue damaged by the sutures.
A healthy indirect closure provides a longer reaction (inflammatory) phase and a more thorough natural debridement.
Certain of these wounds are candidates for negative pressure wound therapy (NPWT) (Ubbiak et al., 2008). Secondary wound closure is sometimes the best compromise between immediately suturing a wound to prevent a large scar and leaving the wound open to prevent the development of infection. In certain cases, negative pressure wound therapy (NPWT) is indicated, in which the negative pressure applied to the wound using sponge dressing and vacuum unit speeds healing and closure (Blume et al., 2008).
The patient, a household member, or a home healthcare nurse is enlisted to repack the wound with saline-moistened sterile gauze and to re-cover it with a dry dressing once each day or as ordered (see instructions below).
In the former case, a registered nurse from a home healthcare agency will be involved in managing the IV medication and the medication delivery system. If there is no evidence of infection and if the edges of the wound can be pulled together without too much tension, the physician can then suture the wound closed. A direct closure that has been delayed only a few days will produce a scar not much larger than if the wound had been directly closed immediately.
If a hematoma or a seroma forms in a closed wound, it will push the edges apart, slow the healing processes, and increase the chance of infection. Sutures are the best choice for wounds that are being pulled apart by tension from the surrounding tissues and for wounds that require detailed matching of the opposing edges. When closing a wound with sutures, the edges of the wound layers are aligned carefully and held together strongly. They can be applied quickly and without additional anesthesia, pose very little added risk of infection, and are inexpensive. If the skin is oily or sweaty, wipe it thoroughly; you can even carefully use a solvent such as acetone to wipe the adjacent skin. Each strip should be long enough to extend beyond the wound about 1 inch (2.5 cm) on either side. Glues are also disrupted by petroleum-based ointments and salves, which should not be used on glued wounds.
Antibiotic ointments are usually not used on a clean wound; they are best used only on infected wounds. The primary layer is put directly on the wound surface, and it is used to keep the wound moist. A nondraining wound can be covered with an occlusive (impermeable) or semi-occlusive (semi-permeable) dressing such as a wound film (see the image below of wound film applied to a burn). Some major dressing companies include Hollister, Convatec, Medline, 3M, Healthpoint, Johnson and Johnson, and De Royal; this is not a complete listing or intended as a recommendation of one brand over another.
Bandages help hold the wound closure in place and can reduce tension across the healing scar.
If there is a large amount of wound drainage or infection, dressing changes can be done more often than daily.
For wounds with minimal drainage, some dressings can last for a week before being changed depending on the location of the wound and activity type and level of the patient.
It is important to be aware that any time spent in changing a dressing, or even cleansing the wound, will cool down the wound, which can then take several hours to come back up to body temperature after being re-covered. Tetanus is a neurologic disease resulting from the poison produced by Clostridium tetani bacteria.
Most patients will be able to state what bit them and whether the bite was provoked or unprovoked.
Active immunization comes from a 5-dose course of rabies vaccine injections; the effect begins within 7 to 10 days and lasts at least 2 years.
If prophylaxis has been started and subsequent tests find that the offending animal did not have rabies, the treatment regimen can always be stopped safely. Surgically, all open, fresh, accidental, or penetrating wounds are considered to be potentially contaminated wounds, and some physicians use this as a reason for giving anti–skin flora antibiotics such as cefazolin.
There is no one standard antibiotic regimen for wounds at high risk of infection, and there is no universal agreement on how long the antibiotic prophylaxis should last. If systemic antibiotic prophylaxis is ordered, the wound will probably be treated with indirect or delayed direct wound closure.
A minor burn cannot be across a major joint, and it cannot be in a band extending around any part of the body. Burns may continue to worsen, especially in the case of radiation therapy burns, which can arise one week after treatment ends or as long as 20 years later. First-degree burns, such as sunburns, are called epidermal burns because the damage is mainly to the outermost layer of the skin. They go all the way through the dermis, and they require treatment in a specialized burn center.
Full-thickness burns can give the appearance of intact skin, but burn areas lack sensation.
Gloves are to be worn and changed after removing old dressings, after cleansing the burn, and especially when applying new dressings.
Wild Iris Medical Education, Inc., provides educational activities that are free from bias. Germinative cells are specialized stem cells that continually divide to give off keratinocytes, the main cells in the remainder of the epidermis.
The deepest layer has thick interlacing collagen and elastic fibers arranged in parallel rows. When cleansing a wound that has penetrated deeper than the dermis, the subcutaneous compartments should be washed out thoroughly to reduce the risk of infection. Ulcers often have destruction of tissue in a broad, roughly circular area (Ethridge et al., 2008). Scars are mainly connective tissue and cannot replicate the specialized functions of the original injured tissue.
For example, infections, tissue necrosis, sebaceous skin, and wounds perpendicular to natural lines of minimal skin tension will all lead to scars that are larger than normal. Scars built of too many cells (mainly fibroblasts) are called desmoids or aggressive fibromatoses. Unlike hypertrophic scars, keloids develop late in the healing process; they can show up months or even years after the injury. The physician may order physical therapy as part of after-care to prevent another contracture from forming. In all wounds, the scar matures and becomes stronger over the course of weeks, months, or even years. The blood coagulation process releases chemical activators from inside entrapped blood platelets; these activators increase the capillary permeability and attract wandering tissue cells (macrophages) and white blood cells. Instead, the accumulating fluid, cells, and clotting materials form a pale yellowish viscous exudate which dries, forming a crust or, if stringy, a slough. Neutrophils live for less than 24 hours, so in a healthy wound, most neutrophils are gone by about day 3. Macrophages are scavengers that continue to debride (or cleanse) the wound biologically by removing dead and dying bits of tissue, dirt, and bacteria.

These epithelial cells come from germinative cells in the adjacent skin, and the new epithelial cells will eventually give rise to the epidermis covering the scar. The scar tissue contracts, edema disappears, and the wounded region continues to strengthen and to adjust to the tensions applied during day-to-day life. Significant contraction occurs mainly in large wounds, such as ulcers, that are not yet entirely covered by a regrown epithelium.
Pushes and pulls that would have no effect on healthy parts of the body can reopen a healing wound, even when it is protected by a well-made dressing.
Anything that decreases the effectiveness of the local circulation will impede wound healing and weaken the scar.
Movement changes skin tension: bending a joint stretches the overlying skin, while contracting a muscle tends to reduce tension in the overlying skin.
In places where the wounded skin is under greater tension, the wound gapes more widely and heals more slowly, and the resulting scar is relatively large. Scars formed by diabetics have less collagen, and the collagen that is laid down is more brittle than normal. Finally, diabetics have a weakened inflammatory response, and they are more susceptible than other people to developing tissue infections. Vitamin A deficiency impedes the transformation of monocytes into macrophages, which can slow or halt healing. However, healthcare providers’ efforts at facilitating wound healing sometimes introduce new impediments.
Moisturizing creams such as Eucerin and topical steroids such as triamcinolone should not be used in open wounds.
For example, a 4x4 with some blood on its surface that will dry in a few minutes can go into the general waste stream. Although they will be wearing face masks, medical personnel who have upper respiratory infections should further protect their patients by not talking or coughing while leaning over wounds.
Nonetheless, we can remove many obstacles that inhibit the body’s innate wound repair mechanisms. Today, we can give natural healing mechanisms a much better chance of success because we have the technology to stop serious bleeding, to cleanse the wound well, and to close surgically (or otherwise effectively protect) large wounds. The history should also include the patient’s chronic illnesses, medical conditions, current medicines, and allergies, as well as the immunization history for tetanus. The injured area and the more distal areas of the body are tested for full sensation, full muscle movement, and adequate circulation.
Another commonly used solution is 1% povidone-iodine (Betadine solution, not 10% Betadine scrub), which is then followed by flushing with sterile 0.9% saline solution.
Secondary wound closures tend to leave a larger scar, but they avoid protecting bacteria inside a warm moist tissue environment.
Delayed primary closure is used for highly contaminated wounds that may need repeated debridement or may need to be treated with antibiotics before being closed.
In addition, immediate primary closure protects from drying any exposed deep tissues and structures such as nerves, blood vessels, tendons, or bones. Clean, unsutured wounds are less likely to become infected than unclean sutured wounds (Kimbell et al., 2009). Moreover, if infection does develop in an indirect closure, there is direct access to the inside of the wound, so it can be debrided, irrigated, and treated with antibiotic. Although the physician may send a patient home with oral antibiotics, this is usually not necessary.
Underlying soft tissue may be closed to eliminate dead spaces that may allow hematoma or seroma formation.
The physician will leave spaces between the strips of tape to allow fluid and exudate to escape and be absorbed by the overlying dressing.
Moreover, metal staples are nonreactive, and they produce less inflammation and shorter healing times than sutures. For skin tears, carefully tease any attached skin flap using a cotton tipped applicator to lay flat onto the open area, reapproximating its edges as much as possible. Fix an end of each tape strip onto the skin at one side of the wound and across the wound to the closest area of intact skin. After putting strips across the full length of the wound, lay a single long thin strip of tape along the ends of the cross strips on either side of the wound, like a railroad track on railroad ties. Ointments will dissolve tissue glues and should not be put on wounds that have been closed with adhesives. The secondary dressing is the outer layer, and it is used to absorb excess drainage and to protect the wound.
In addition, the compression provided by a bandage will reduce the open space (dead space) in a wound and thus discourage hematomas and edema. All bandages should be smooth and unwrinkled and should apply pressure equally across a wound. Wounds with significant drainage should have secondary dressings that are sufficiently absorbent to back up the primary dressing in case of overflow of wound exudates.
Consideration must be given regarding the new strains of bacteria that are resistant to the more commonly used antibiotics. The tissue under these blisters is moist and pink, and it is extremely sensitive; even air currents can be painful. In the emergency room, it can be difficult to distinguish between partial-thickness burns and full-thickness burns. Patients with these burns are referred to the nearest specialized burn center and transported as soon as possible after being stabilized.
All old dressing materials, gloves, and items used in cleaning should be disposed of as bio-hazardous waste. As they age, the new keratinocytes fill with keratin (a tough fibrous protein) and are pushed to the surface, where they die; thus, the outermost layer of the epidermis is made of flat, dead keratinocytes.
The dermis varies in thickness across the surface of the body, but everywhere it is significantly thicker than the overlying epidermis. The extracellular fibers in the deep dermis are responsible for the strength and toughness of the skin. If a wound reopens before it is effectively sealed (called dehiscence), the scar will be wider and, usually, weaker. In hypertrophic scars, the excessive formation of collagen usually stops within a few weeks. Disabling contractures most commonly form across finger joints, along the neck, across the axilla, and across the antecubital fossa. In infected wounds, however, neutrophils continue to pour in, and as they die, they accumulate to form pus, thus prolonging inflammation. Macrophages also release growth factors, chemicals that stimulate the growth of fibroblasts, endothelial cells, and epithelial cells, all of which are players in the next phase of wound healing. Together, the newly forming cells, blood vessels, and loose extracellular matrix are called granulation tissue.
Besides making collagen, fibroblasts also secrete sticky amorphous extracellular matrix molecules, the glycoproteins.
But these neutrophils die after 24 hours, and when they are continuing to infiltrate the wound because of persistent contamination, the dead neutrophils pile up and begin to clog the wound in the form of pus. Skin creases and skin wrinkles are indications of lines of least tension; on the face, the lines of facial expression are also lines of least tension.
Obesity increases tension on the abdomen and difficulty due to movement of the panniculus (overhanging folds of subcutaneous fat), particularly to the sides and away from center line. Cancer therapies, however, give relatively high doses of ionizing radiation, and in areas of the body exposed to radiation therapy, wounds heal poorly and infections are more common.
If any major neural or vascular problems are suspected, a surgical specialist is usually notified. Medication should be administered in advance of the procedure, and the procedure begun only after the onset of action of the drug(s).
To achieve the thinnest scars, surgeons make elective incisions in or parallel to skin creases and perpendicular to underlying muscles.
For highly contaminated wounds, secondary closure significantly reduces the risk of infection. On the other hand, metal staples are less comfortable for the patient, and they tend to leave a patterned scar. Tape and tape-like products are not as strong as staples or sutures, and do not work well for gaping wounds or for wounds that will be under tension, such as those across joints. In the first-aid setting, both tape and glue are frequently used for closing small lacerations by nonmedical people, as both are easily available. For any wound, do not apply ointments containing corticosteroids, which impede wound healing. They also keep the wound from drying out, while at the same time absorbing excess fluid and exudate, both of which can slow healing. Ideally, the full dressing should protect the wound from bacteria and dirt while allowing water vapor to diffuse away from the wound.
Bandages also protect against injuries to the healing wound by providing an additional layer of padding and by reducing the mobility of the wound area. Fix the bandage in place with tape, minimizing tape directly on skin, and make sure it feels firm, but do not make the bandage so tight that it impedes circulation. Even in the best hospital settings, tetanus has a fatality rate of 10% or more (Tiwari et al., 2011). Public health officials will also try to find the animal if there is any chance that it might be rabid. Consult with local public officials and review the latest CDC recommendations for rabies prophylaxis.
In some cases, wound culturing and sensitivity testing is used if resistant bacteria are suspected.
Superficial partial-thickness burns, in which the epidermis and the top portion of the dermis is affected, will heal in 2 to 3 weeks, leaving minor scarring with a lighter pigmentation than the surrounding skin. Large burn blisters and those over mobile joints are usually opened, and the blister roof is entirely removed by the physician.
The epidermis also contains melanocytes (pigment-containing cells) and immune system cells. When a wound is closed with sutures, they are anchored in the strong connective tissue of the lower layer of the dermis. If too few capillaries grow into the forming scar tissue, leading to ischemia, the scar will be very weak and may develop into an ulcer.
When excessive scars form tight ridges along the skin and permanently interfere with normal movement, they are called contractures. The result is a scar that is thicker than normal and is raised above the plane of the skin, but unlike a keloid, a hypertrophic scar does not expand out beyond the actual wound. Keloids, which do not regress spontaneously, are usually found on the upper half of the body.
Over a period of 3 to 4 days, the myofibroblasts in the scar contract and slowly shrink the wound (Ethridge et al., 2008). Pus slows the formation of granulation tissue and the re-epithelialization of the wound, giving bacteria still more time to multiply.
As a rule, the lines of least skin tension are perpendicular to the long axis of underlying muscles. Mechanical scrubbing with an antiseptic sponge is effective at removing bacteria and debris, but it is also damaging to the wound tissues.
Physicians will try to make the long axis of the wound seam parallel to skin creases, perpendicular to underlying muscles, and along the local line of least skin tension.
The choice between absorbable versus nonabsorbable suture is influenced by considerations such as the strength required, the possibility of scar formation, and the cooperation of the patient with suture removal.
Metal staples should not be used on facial wounds or other areas where appearance is important. In the case of adhesive allergies or sensitivities, use of skin protectants (such as Cavilon or SkinPrep) may help to reduce sensitivity to adhesives. On the other hand, once a wound is infected, a thick dressing will encourage bacterial growth; therefore, thick or impermeable dressings are not put over infected wounds.
Also available are joint immobilizers, which can be soft (like a sling) or rigid (like a knee brace).
For adults, the CDC recommends a routine booster dose of tetanus toxoid–containing vaccine every 10 years.
Deeper partial-thickness burns, involving epidermis and large portions of dermis tissue, will heal in 3 to 6 weeks and will leave significant scars. The epidermis, a protective layer that is normally impermeable to water, does not have sufficient strength to hold sutures or staples. Hypertrophic scars, which usually get smaller spontaneously, can occur anywhere on the body. Healthy granulation tissue contains newly growing blood vessels and should be beefy red with a bumpy, uneven surface. Furthermore, many bacteria secrete toxins that add to the tissue damage in the wound when it has become infected. To close the skin, jagged wound edges are matched carefully as long as the skin along the edges is still viable.
Before beginning, pain control should be given, as partial thickness burns can be very painful and even sensitive to air flow.
Each stitch is gently tightened so that the edges are everted and touching but are not crushed together.

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