Minor Surgical Procedures in Remote Areas (MSF, 1989, 172 p.) Chapter 1: Wounds - Burns Dressings Wounds Burns

Minor Surgical Procedures in Remote Areas (MSF, 1989, 172 p.)

Chapter 1: Wounds - Burns

Dressings

Dressing is a set of procedures for treating a wound. A wound is an interruption in the continuity of the skin secondary to trauma or surgery.

Objectives

· Protection:

- To prevent contamination from the external environment
- To protect against possible trauma

· Cicatrisation:

- To favor tissue regeneration

· Absorption:

- To absorb serous discharge

· Disinfection:

- To destroy pathogenic organisms

· Compression:

- To stop hemorrhage

Warning: A dressing occludes a wound and in certain conditions (humidity, heat) can encourage multiplication of pathogenic organisms.

Equipment

· 1 box of sterile instruments - 1 set of dissection forceps - 1 set of Kocher forceps - 1 pair of scissors
· 1 dressing tray (clean)
· 1 drum of sterile gauze pads
· 1 kidney dish
· Cotton wool (for equipment disinfection only, never use cotton wool directly on a wound)
· Adhesive tape
· Flasks containing antiseptics: chloramine and/or cetrimide-chlorhexidine, and polyvidone iodine (dilution: see table).
N. B. : Never use polyvidone iodine with soaps containing mercurial derivatives.
Solution preparation should be rigorous. Solutions should be renewed every week (every 3 days for chloramine).

General rules of asepsis

· A room should be kept for dressings. It should be carefully cleaned everyday and dressing tables should be disinfected between each patient.
· Use a sterile box of instruments for each dressing, or at least for each patient.
· Always start from the clean area and move to the dirty one.
· Wash hands carefully after each dressing, and after removing bandages or adhesive tape.

Technique

Equipment and instrument preparation

· Cleaning of the dressing tray with cetrimide-chlorhexidine (dilution: see table).

· Removal of the previous dressing

· Removal of bandages and adhesive tape (not the gauze pads)

· Hand washing (clean water + soap)

· Removal of gauze pads, using Kocher forceps

- If the dressing adheres, soak it with sodium chloride solution or an antiseptic.
- Act gently not to remove the granulating epidermis.

Wound examination

· Sutured wound and/or aseptic wound:

- Check the stage of cicatrization if wound is weeping, has a hematoma, or is infected.

· Septic wound:

- Check the nature of secretions and if there are new fleshy pimples.
- A bluish pus indicates the presence of pyocianic (quickly spreading, very resistant bacillus spreading very quickly).
- Look for any signs of lymphangitis.
- Use new forceps after removal of the dirty dressing and the first cleaning of the wound.

Cleaning of the wound

· Use the sterile dissection forceps to remove sterile gauze pads from the container, and place them on the tray.

· To make a sterile sponge fold the pads twice using the Kocher and dissection forceps (as illustrated).

FIGURE

· Pour an antiseptic solution on the pad (infected wound, bures, abcess, ulcers: cetrimide-chlorhexidine; non infected surgical wound: polyvidone iodine (dilution: see table, page 7).

· Clean the periphery of the wound either with a circuler movement, or from top to bottom. Change gauze pads as often as necessary.

· Clean the wound from top to bottom with a new tampon.

· Dry the periphery of the wound and then the wound itself with different gauze pads.

Dressing a wound

· Apply one or several gauze pads to the wound

· Apply strips of adhesive tape: - Perpendicularly to the axis of the limb or the body - Leave the central part free to avoid maceration

N.B.: When sterile disposable material is limited, sterile pads should be reserved for aseptic and surgical wounds.

Frequency of dressings

· Surgical wounds, or non infected sutures: - First day dressing should be well protected - Further dressings, every 48 to 72 h (check the process of recovery).

· Infected wounds: - Dress every 24 h.

· Deep or large burns:

- Dress on the first day, then leave until the 7th day (unless obvious infection)

· Phagedenic ulcers:

- Dress every 24 h, with hospitalization if possible.

Associated antibiotic treatment

As a rule, systemic antibiotic treatment should not be prescribed routinely.

· Deep and soiled wounds, to prevent gas gangrene: procain-penicillin (IM) : 4 or 5 IU per day x 5 days at least.

· Abcess: antibiotic treatment is useless before incision.

· Burns: only if they are infected.

· During conflicts or other disaster relief conditions, where access to health care and patient's follow-up are hazardous, the systematic use of PPF (or procain-penicillin) should be considered.

Wastes

All soiled disposable materials (gauze, coton, dressings, etc.) should be collected and burned daily.

TABLE 1

Wounds

General principles

This chapter concerns only wounds that can be treated at a dispensary lever. For major trauma, refer to a surgical manuel.

· Immediate ("primary") closure of wounds is desirable but not always practicable and in some circumstances it may be dangerous (risk of infection).

· Classically, it is said that a wound of greater then 6 hours should not be sutured. In isolated rural practice, however, patients often present fate because of distances and this limit may be extended up to 24 hours, provided the patient can be observed during the following days for signs of infection.

· An infected wound should never be sutured.

· War wounds, animal and human bises should not be sutured.

· Any break in the skin overlying a fracture is an "open fracture".

· A wound that communicates with a joint is an open joint wound.

· Always give antitetanus prophylaxie if available.

The following are steps in the treatment of a wound: preparation, explo-ration, debridement, closure, drainage, and finally removal of sutures.

Preparation
Wound toiles

· Shave if necessary, then clean the wound and its periphery with iodine povidone Betadine

Material
(Figures 1a a 1d et 2a a 2c)

· Sterile gloves and fenestrated drapes.

· Lidocaine, needle and syringe.

· Suture material.

· Suture set (sterilized box of instruments): needle holder, needles, scalpel brade and handle, one or two artery forceps, fine curved scissors with rounded ends, plain scissors for cutting sutures, retractors.

Local anesthesia

· Only necessary for large or deep wounds requiring more then 2 stitches.

· Lidocaine 1% without adrenaline.

· Infiltrate subcutaneously via the wound edges.

Exploration

Once anesthetized, the wound can be explored and thoroughly cleaned of any debris. Have a gloved assistant usina retractors if necessary. Be careful to exclude the following:

· Foreign body.

· Underlying fracture.

· Involvement of nerves, major blood vessels, tendons or joints.

· For scalp wounds: underlying fracture (if serious may contain braie tissue).

Closure

· Use interrupted sutures (not continuous).

· Non-resorbable sutures such as silk for skin, resorbable thread (chromic catgut, Vicryl.) for subcutaneous tissues.

· Some suture material is already mounted on a needle by the manufacturer ("atraumatic needles").

· A curved needle is casier to manipulate.

· For skin use a "cutting" needle (triangular in cross-section); for subcutaneous tissues use a "round" needle (circuler in cross-section).

TABLE 2

Drainage

· Use a strip of corrugated rubber drain.

· Never use a drain for wounds of the face.

· Always insert a drain in wounds of the scalp and whenever a hematoma can be expected to form.

Removal of sutures

· Face: day 5.
· Other wounds: day 7 or 8.

FIGURE

FIGURE

FIGURE

FIGURE

FIGURE

FIGURE

FIGURE

FIGURE

FIGURE

FIGURE

FIGURE

FIGURE

FIGURE

FIGURE

FIGURE

FIGURE

Burns

Thermal trauma to the skin, mucosa and deeper tissues. Burns are classified according to depth and extent.

Any burn that affects greater then 10 % of the body surface area is considered extensive and is thus serious because of fluid loss, catabolism, anemia and the risk of secondary infection. Burns are very common in rural societies, particularly among children who fall onto or roll into cooking fires.

Clinical features

The extent of a burn is expressed as a percentage of total body surface area involved, easily estimated by the "rule of nines" (Table 3). The degree is a function of the depth to which tissue damage penetrates (Table 4).

A patient with extensive bures is likely to be in shock and requires appropriate resuscitation. Among children, the younger the patient the graver the danger presented by a burn of given extent and degree.

TABLE 3

TABLE 4

Treatment

First aid

· Immerse in cold water; this provides good analgesia and also arrests on-going trauma due to the heat retained in the tissues.

· Apply gentian violet.

· Do not cover.

Resuscitation

· Calculate the fluid requirements for the first 24 hours: weight x % of surface burn x 2 = quantity of fluid required in mls. e.g.: 60 kg (wt) x 20 % (extent of burn)
60x20x2=2,400ml
- 75 % of fluid should be given or Ringers Lactate, the remainder as volume expanders or blood transfusion.

· During the first 24 hours, half the fluid requirements should be given in the first 8 hours.

First dressing of the burn

· Analgesia pentazocine (IM): 30 mg) and sedation if necessary (diazepam (IM): 10 mg).

· Tetanus prophylaxie if available.

· Strict aseptic technique: drapes, gloves and instruments all sterile (Figure 15).

· Clean the burn with normal saline or chlorhexldine-cetrimide solution (see table, page 7).

· Use a scalpel to debride blisters and non-viable tissue.

· Apply sterile vaseline gauze, then on top of that two layers of unfolded sterile gauze swabs. Do not use either antibiotic ointment or gauze impregnated with antibiotics or corticosteroids.

- Apply a bandage, not tightlv. Do not wrap limbs, especially at the flexures as this will encourage contractures. Bandage each finger separately, never together.

· Immobilize limbs in the position of function.

· Alternatively: "open method": after wound cleaning leave the burn uncovered with the patient protected by a mosquito net.

Subsequent dressings

· Unless infection ensues, the first dressing should be left undisturbed for 5 to 7 days.

· Analgesia aseptic technique as for the first dressing.

· Remove any black eschars (which may hide purulent areas) and use scalpel to excise any necrotic tissue: skin, aponeurosis, muscle or tendon.

· Systemic antibiotics if obvious infection (not antibiotic ointment): PPF (IM):

Adult : 4 MIU/day x 5 days at least
Child : 100,000 IU/kg/day x 5 days at least

· Same dressing as the first time. Again, this should not be removed for 5 to 7 days. Healing is signaled by granulation tissue: pink, mat and clean.

Patch grafting

(Figure 16)

· Skin grafting is necessary when the wound is slow to heal: often the case with deep second degree and third degree burns. Patch grafting is a simple technique and can also be used for treating tropical ulcers once the base is clean and granulating.

· Aseptic technique. Shave the donor area (usually anterior thigh or forearm) and prep with povidone-iodine (see table, page 7). Infiltrate with lidocaine 1%.

· Lift up a patch of skin with fine toothed forceps and excise it with a scalpel. It should be full-thickness i.e. epidermis plus dermis. Take other patches from different parts of the donor site, leaving areas of intact skin between each excision.

· Spread each patch out on a sterile swab dampened with normal saline.

· Once a sufficient number of patches are excised, apply them carefully to the wound. Do not place them too close together: further healing will bridge the gaps and this allows a larger area to be grafted.

· Dress the donor and graft sites with sterile vaseline gauze, then layers of swabs and a non-compressive bandage.

· The graft will take within 7 days, during which time the dressing should not be removed and the patient should remain as immobile as possible.

FIGURE

FIGURE