THE IMMEDIATE WOUND TOILET

Here is a general method for most wounds, large or small. Goto other sections for wounds of a patient’s scalp (63.6), his face (61.1), or his hands (75.1).

ADMISSION Don’t hesitate to admit a patient, even if he has quite a minor wound, especially if it is below his knee, in his buttock or his perineum, or on his abdomen or chest.

X-RAYS If he might have a foreign body or a fracture, X-ray his wound in two planes to locate it. Glass is usually radio-opaque.

INDICATIONS All wounds need some kind of toilet. The simplest toilet (applicable, say, to eyelid wounds) is dabbing on antiseptic after ordinary washing and exploring to remove obvious dirt. Most wounds need more than this, some very much more. The more the dead tissue, the more thorough must be your toilet.

CONTRAINDICATIONS The contraindications to a radical toilet are signs of established infection, such as a foul discharge, lymphangitis, lymphadenitis, or fever. You will not find them in wounds under 6 hours old, so with these wounds you can always do a radical toilet.

EQUIPMENT A minor operation set (4.11), two fairly soft nail brushes, two skin hooks, soft rubber tubing for a finger tourniquet, or a pneumatic tourniquet. Several litres of clean water, which need not be boiled. Saline is better; make it by adding two level teaspoonfuls of salt to a litre of water. Soap and aqueous chlorhexidine. You will need a good light. If you are in any doubt, use the main theatre.

TOURNIQUET A tourniquet may sometimes be useful, but don’t use one routinely, because it makes distinguishing between living and dead tissue more difficult.

ANTIBIOTICS A thorough wound toilet is more important than any antibiotic. If a patient’s wound is severe and particularly if it is heavily contaminated, give him a perioperative antibiotic, as in Section 2.7, before you start his surgical toilet.

ANAESTHESIA Don’t hestitate to anaesthetize a patient, even if his wound is quite small. You cannot toilet it adequately if he is conscious.

If he might have injured his nerves and tendons, test them before you anaesthetize him—clinical tests while he is conscious are more reliable than poking about in his wound after he is anaesthetized.

If his wound is large, use regional or general anaesthesia. Ketamine is adequate.

If a patient’s wound is small, you can do a nerve block, or you can use a fine needle to inject local anaesthetic solution from his wound into the surrounding tissues. This is particularly useful in children.

THE SOCIAL TOILET OF A WOUND

Do this in two stages before you drape a patient, first the surrounding skin, then the wound.

(1) Pack the patient’s wound with a sterile swab to keep it dry while you clean the skin around it with tap water, ordinary soap, and a nail brush. Ask your assistant to pour on more tap water, until the patient’s skin is very clean.

(2) Now remove the swab and clean the wound itself. If the dirt is ingrained, use a fresh soft boiled nail brush and gloved or scrubbed hands. You can use a nail brush in a wound. Push it into the dirty tissues of the wound with gentle rotating movements. Don’t use vigorous side to side scrubbing movements. Put a basin under the wound, so that your assistant can pour clean water over it continually. Don’t immerse it in a basin of water.

THE SURGICAL TOILET OF A WOUND

Paint the skin round the wound with cetrimide or chlorhexidine. Don’t use iodine, because this will damage more tissue. Drape it.

CAUTION! Treat the tissues kindly. Don’t grab them with large artery forceps, or swab them violently; this injures them, and makes them less able to resist infection.

Use a scalpel and a pair of forceps to cut away all dirt and ingrained mud etc. Flush smaller foreign bodies out of the wound with sterile Ringer’s lactate, saline, or sterile water in a 50 ml syringe, or an ear syringe. You may find pieces of wood, metal, gravel or clothing. Explore the patient’s wound. Probing for foreign material is not enough. If necessary, open it widely to look into its depths.

If, for any reason, you have to leave a foreign body, such as deeply embedded bullet, tell the patient so.

Remove all clots and join up all cavities so that they drain readily.

EXTEND THE WOUND, if necessary, in the length of the limb. If you have to open up a flexure, make an S–shaped incision, as in Fig. 54-3. If nerves or vessels have been injured, extend his wound appropriately to reach them.

INJURED TISSUES IN A WOUND

Injured skin. Except on the patient’s face cut away 3 mm of the skin margin round the wound, as in A, Fig. 54-4. Don’t undermine the skin edges.

Injured fat readily necroses, so cut it back freely until you reach healthy yellow fat which is not bruised.

Injured muscle and fascia. Cut away all torn fascia and open up fascial planes (B). Put retractors in the wound so that you can see inside it. Cut away all dead muscle (C). Dead muscle looks darker and bluish, it does not bleed or ooze when you cut it, and it does not contract when you pinch it with forceps. Snip it away until you reach healthy muscle which contracts and oozes where you cut it. Be radical, dead mus- cle is an ideal culture medium for clostridia. If you are in doubt as to whether muscle is alive or dead, cut it out! The patient has muscle to spare and will not miss it.

If there are loose pieces of bone which are not attached to periosteum or muscle, they are ischaemic and will die anyway. Remove them. Leave pieces which are still attached to periosteum. Don’t scrape live muscle or periosteum from the surface of a bone, because the bone under it may die.

If his bone is exposed in the wound, there are several things you can do:

If there is muscle nearby, use this to cover the exposed bone. This is usually easy with the femur, the radius or the ulna, because reduction (usually traction) will pull the bone back into the wound. Covering an exposed tibia is not so easy.

If the exposed area of bone is large. you can cover it with moist gauze. Apply sterile saline several times a day, and change the gauze daily. After several months the outer cortex of the bone will slough and you can graft the granulations under it.

If the exposed area is clean, you can graft it with split skin. If this later falls off to leave white dry bone, chisel it away until you reach red cancellous bone, as in Fig. 81-12. You can graft this immediately, but it is probably wise to wait 3 or 4 days for a bed of suitable granulations to form.

If tendons lie exposed see if they are covered by paratenon (the normal fine vascular covering of a tendon). A split skin graft will not take on naked white or dry tendons, but it will usually take if they are still covered by paratenon. If the extensor tendons of a patient’s hand are exposed, and there is no such layer, and you cannot refer him, consider doing the groin flap in Section 75-27. If you can refer, him cover his tendons temporarily with split skin and vaseline gauze.

If nerves or vessels are exposed, try to cover them with adjacent tissue, or a simple flap, as in Section 57.11.

If you are not sure if tissue is alive or dead, it is alive if it bleeds or blanches on pressure. If you are still not sure, inspect the wound at 48 hours and remove more dead tissue if necessary. This is wiser than waiting for infection.

SPECIAL STRUCTURES If clinical examination shows that a nerve has been injured, explore it and look at it. If one side is gaping, clean it carefully and suture the epineurium to approximate the ends accurately.

Look elsewhere for the treatment of cut tendons (55.11), cut nerves (55.9), torn arteries (55.6), open fractures (69.7), and open joint wounds (69.8).

RELIEVING TENSION IN THE WOUND If a patient’s tissues show any tendency to burst out of his wound, open up his deep fascia longitudinally down the whole length of the muscle compartment involved. This will prevent the compartment syndrome (70.4), and is especially important in the forearm (73.7) and the lower leg (81.14); it may even hasten the union of a fracture.

CONTROLLING BLEEDING FROM A WOUND

If you are using a tourniquet, release it. If bleeding is very severe, see Section 55.1.

If you are not using a tourniquet, bleeding or oozing should start as you cut away dead tissue. If it does not, you have not yet reached viable tissues, so you are not cutting away enough. If the wound is extensive, pack one part of it while you clean another.

Most of the bleeding will probably have stopped by the time you have finished toileting the wound. If larger arteries spurt at you, tie them with silk or linen thread. Tie smaller vessels with fine monofilament. Avoid catgut, especially thick catgut, because it makes a good culture medium.

If necessary, control oozing with packs (3.1), leave them on for 10 or 20 minutes, and apply more if necessary.

SUTURES AND DRESSINGS If you have had to do an extensive wound toilet, the wound will not be suitable for immediate primary suture. So pack it with gauze, as in D Fig. 54-4. Aim for dryness and coolness. Loosely bandage the gauze in place, making sure the bandages do not restrict the circulation.

If the wound is in a limb, raise it (75-1, 81-1).

PREVENT TETANUS in all wounds, as in Section 54.11.

PREVENT GAS GANGRENE, when necessary, as in Section 54.13. If a patient has a severe muscle wound of his buttock, thigh, calf, axilla, or retroperitoneal tissues, give him penicillin 1.5 megaunits every 4 hours starting immediately after the injury. Or, give him tetracycline.

SPLINTS TO IMMOBILIZE THE LIMB If he has a severe wound of a limb, immobilize it. Skeletal traction is safest. Or, use a plaster back slab. If you use a circular cast, bivalve it immediately, a slit down one side is not enough to prevent swelling. Elevate it.

A SECOND SURGICAL TOILET If you see more dead tissue at the time of the delayed closure, toilet his wound again.

THE COMMON MISTAKES IS FOR A WOUND TOILET NOT TO BE THOROUGH ENOUGH