SECONDARY WOUND TOILET

INDICATIONS Infected wounds 8 hours or more after the injury.

METHOD If any stitches have already been placed in the patient’s wound, remove them and lay it open. If necessary relieve tension by splitting the fascia. If pus is present, culture it. If the edges of the wound are acutely inflamed, or there is lymphangitis, lymphadenitis, or fever, give the patient an antibiotic, and make sure you toilet his wound under antibiotic cover, or you may spread the infection and cause septicaemia. If he has none of these signs, antibiotics are unlikely to be helpful. Remove all necrotic tissue; open up any pockets of pus; remove any infected blood clot, dead bone or foreign bodies.

Be cautious and try not to open up tissue planes at a distance from the edges of his wound. This is especially important if you have no adequate antibiotic.

Eliminate any dead spaces, and provide dependent drainage. Pack the wound with dry gauze or apply a hypochlorite (’Eusol’) dressing.

You will probably be able to close the wound some days later by delayed primary suture or by grafting. Immobilize the patient’s wound, and elevate his limb (81-1, 75-1).

DIFFICULTIES WITH AN INFECTED WOUND

If a patient’s WOUND IS LARGE, and continues to discharge for many days, check his haemoglobin, transfuse him if necessary, and give him a high protein diet.

If his INFECTED, STINKING, DISCHARGING WOUND IS DIFFICULT TO MANAGE, try: (1) Soaking it in a bucket or a bath. (2) Immobilizing it in plaster gutter or splint. Lay it widely open and pack it with gauze. If the wound is not too big, and you need to immobilize a fracture, cover it with a complete cast, and cut a window in it. Make sure the dressings compress it firmly to stop it herniating.