Management of Acute Skin Trauma

Joel W.Beam，EdD，LAT，ATC

University of North Florida，Brooks College of Health

Acute skin trauma（ie，abrasions， avulsions，blisters， incisions， lacerations， and punctures） is common among individuals involved in work， recreational， and athletic activities. Appropriate management of these wounds is important to promote healing and lessen the risk of cross-contamination and infection.Wound management techniques have undergone significant changes in the past 40 years but many clinicians continue to manage acute skin trauma with long-established，traditional techniques （ie， use of hydrogen peroxide， adhesive strips/patches， sterilegauze， orno dressing） thatcan delay healing and increase the risk of infection.The purpose of this review is to discuss evidence-based cleansing， debridement， and dressing techniques for the management of acute skin trauma.

Cleansing

Wound cleansing is the delivery of a solution to the wound bed and/or periwound tissues through a mechanical force to remove foreign bodies and debris，excess exu date， and microorganisms[1].Whirlpool baths and soaks，scrubbing and swabbing，and irrigation are common methods used for cleansing.Whirlpool baths and soaks involve immersion in a whirlpool or container to remove foreign bodies and debris.This technique is painless but increases the risk of cross-contamination from contaminates in the tub or container and water additives and can cause tissue damage from excessive water turbulence[2].Scrubbing and swabbing consists of direct contact with the wound bed and is indicated in cases of gross contamination with debris such as dirt， grass， and sand.Scrubbing and swabbing is typically performed by moving a moistened gauze pad across the wound bed in a circular pattern.This method has shown to only redistribute microorganisms over the wound bed with no reduction in bacterial bioburden and can damage tissues[3].However，scrubbing and swabbing can be used to cleanse intact periwound tissues without damage.Irrigation is the controlled delivery of a solution to the wound bed and has been found to effectively remove foreign bodies， excess exudate， and microorganisms without causing tissue damage.Delivery of a solution to the wound should occur between 4 and 15 pounds per square inch（psi）.A 35-mL syringe with a 19 gauge needle hub or plastic cannula delivers a solution around 8 psi.Most agree that irrigation is the preferred cleansing technique for acute skin trauma [4].However，splash-back and exposure to disease are concerns with irrigation.Irrigation，along with all cleansing，debridement，and dressing techniques，should be performed following universal precautions.

Solutions used for wound cleansing should be non-toxic to tissues，non-allergenic，effective in reducing bacterial bioburden，and cost-effective.Among common solutions，sterile 0.9%saline is described as completely safe for use with acute skin trauma.Po
Table tap water supplied through non-contaminated pipes and nozzles or distilled water is widely available and cost-effective as a cleansing solution.A Cochrane Database of Systematic Reviews report[5]found no differences in rates of infection between the use of saline and tap water for cleansing of acute wounds.Antiseptics are used for their antimicrobialaction in the decolonization ofmicroorganisms.However，antiseptics can be inactivated by body fluids，hard water，and cellulose products.Based on the cleansing technique，most antiseptics do not remain in contact with the wound bed long enough to reduce bacterialbioburden.Last，antiseptic solutions have been shown to be cytotoxic to fibroblasts and macrophages[2，6].Asaresult， povidone-iodine， hydrogen peroxide， and sodium hypochloriteshould notbe used forcleansing ofthe wound bed，butare safe foruse on intact periwound tissues[2，6].The temperature of the cleansing solution is critical to the healing process.The solution should be delivered to the wound bed at body temperature（98.6°F or 37℃），as temperatures below this level can impede cellularand chemicalactivitiescausing a delay in healing[7，8].See
Table for cleansing techniques for specific wounds.

Table Cleansing，Debridement，and Dressing of Acute Skin Trauma

Clinical Application:For irrigation，place the patient or athlete in a seated，supine，or prone position on a
Table draped with towelsto absorb excessbody fluidsand cleansing solution.Fill the syringe with saline or tap water.Position the needle hub or cannula 4-6 inches from the wound bed and depress the plunger with a back-and-forth motion over the wound. To lessen splash-back，place a gloved hand above the wound.Continue to fill the syringe and irrigate the wound until all visible debris is removed.The periwound tissues can be cleansed with irrigation and/or scrubbing and swabbing.When complete，dry the periwound tissues with sterile gauze.

Debridement

Wound debridement is the removal of materials from the wound bed until only normal， soft， and well-vascularized tissue is present[9].Debridement of necrotic tissue and foreign bodies should be performed immediately following trauma to establish a clean wound bed to promote healing and lessen the risk of infection as necrotic tissue and waste can serve as a culture medium for bacteria[9，10].Mechanical，sharp，and autolytic techniques are effective methods of debridement for acute skin trauma.Irrigation，described as a cleansing technique，is also a method of mechanical debridement for most wounds.Sharp debridement，performed in a clean environment with sterile instruments，is highly selective in the removal of loosely attached necrotic tissue[9].Autolytic debridement is the softening and digesting of necrotic tissue and waste in a moistwound environment.In thisenvironmentcreated through the use of semi-occlusive and occlusive dressings，action of the neutrophils，lymphocytes， and macrophages liquefy and digesttissue and waste.Thisdebridement method is time consuming but is less labor intensive for the clinician[9，10].Irrigation， sharp， and autolytic tech niques can be used individually or in combination to establish a clean，viable wound bed.See
Table fordebridement methods utilized with acute wounds.

ClinicalApplication:To perform sharp debridement，place the patient or athlete in a seated，supine，or prone position on a table.With sterile scissors，tweezers，and/or forceps，gently remove any loosely attached necrotic tissue along the border between viable and nonviable tissue.If a visible border cannot be identified，begin at the center of the nonviable tissue and continue in a circular pattern until reaching viable tissue.Stop if bleeding occurs.

Dressing

Wound dressing is the application of materials to the wound bed to promote healing，reduce pain，contain exudate， lessen risk of cross-contamination and infection，and providemechanicalprotection.Dressingsforacute skin trauma can be categorized into three groups;woven，skin tapes，and semi-occlusive and occlusive.Some woven dressings，such assterile and non-adherentgauze pads，should not be applied directly to the wound bed.These dressings adhere to the wound bed，allow desiccation and cooling of tissues，and require frequent changes which can damage newly formed granulation and epithelial tissue.Sterile and non-adherent gauze dressings do not promote a moist wound environment or provide an impermeable barrier to the external environment，causing a delay in healing and increasing the risk of cross-contamination and infection.Paraffin and impregnated gauze do not adhere to the wound bed and promote a moist wound environment.These dressings wick exudate away from the wound，but require frequent changes.Skin tapes are indicated for superficial，linear lacerations and incisions in areas of minimal static and dynamic tension.Tapes have been shown to produce lower infection rates and tissue damage than traditional suturing [11].Semi-occlu sive and occlusive dressings consist of films，foams，hydrogels， hydrocolloids， and dermal adhesives and maintain a moist wound environment.Wounds in a moist environment have been shown to heal more rapidly，produce less pain，and have lower rates of cross-contamination and infection compared to non-occlusivedressingsand no dressings[12，13，14].Semi-occlusive and occlusive dressings are impermeable to bacteria，possess a waterproof construction，and require fewer dressing changes than non-occlusive dressings.Films are used with superficial-and partial-thickness wounds， but are nonabsorbent.Therefore，use of films with heavily draining wounds is contraindicated.Films can remain on the wound bed up to 7 days.Foams are indicated for partial-and full-thickness wounds and are super absorbent，which allows the dressings to handle excessive wound exudate.Foams can remain over the wound bed for 3-7 days.Hydrogels are composed of 80-90%water and can be used with partial-and full-thicknesswounds.Hydrogelscan remain in place on the wound bed for only 3 days，as the dressing will undergo drying.Hydrocolloidsare indicated forsuperficial-and partial-thickness wounds and can remain on the wound bed up to 7 days.Dermal adhesives are used with lacerations and incisions with easily approximated wound edges in areas of low tension and stress.Supplied through a pen or ampoule，dermal adhesives produce a thin，flexible occlusive dressing with tissue bonding for 5 to 10 days.See
Table for dressing techniques for acute wounds.

Clinical Application:For films， foams， hydrogels， and hydrocolloids，dry the periwound tissues with sterile gauze following cleansing and debridement.Selectthe appropriate dressing and cut（if necessary） the dressing to a shape approximately 2～3 cm larger than the wound bed.Centerthedressing overthewound bed with a minimum of 2 cm of the dressing on the periwound tissues.For active patients and athletes，a secondary dressing can be used to further secure the dressing to the periwound tissues.Monitor and inspect the wound daily for signs of infection （ie，abscess/pus，abnormal heat，edema，erythema，or discharge，abnormal smell，or unexpected pain/tenderness），adverse reactions（ie，contact dermitis， folliculitis， or periwound maceration）， and dressing integrity and leakage.Replacement of semi-occlusive and occlusive dressings is required with leakage from the dressing perimeter.Replacement of foams and hydrogels is necessary when they become filled with exudate.

Currently，there is no one recommended cleansing，debridement，and dressing technique appropriate for every acute wound and healing environment.However，wound management practices among clinicians should be guided by evidence-based data rather than anecdotal evidence or traditional methods.Decisions regarding the use of specific techniques should be based on the type of wound（ie，tissue depth，amount of exudate，and body location），needs and activity level of the patient and athlete（ie，factory worker，office personnel，soccer，or cyclist），and purpose of the cleansing，debridement，and dressing technique.

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