BURNS & WOUNDS: CLINICAL POINTS Urgencias Open wounds should be covered with a sterile dressing to prevent further contamination during handling of the patient. Fractured bones must be protected and may require some form of restraint to prevent further damage to the soft tissues, control shock or pain relieve. Once the patient is stable, we can turn our attention to the proper handling of these problems First aid External bleeding must be stopped applying pressure on the wound site with a clean bandage. If bleeding continuous, apply a new layer of bandage. The first bandage should always be kept in place, because if replaced we might as well be removing the forming clots and cause a larger hemorrhage. Once in the operating room, we can remove this bandage. Definitive treatment The goal of treatment of all open wounds is to change a contaminated wound into a surgically cleaned wound that can be closed. The use of an aseptic technique, proper handling of tissues and proper hemostasis are essential. All open wounds have some potential to become infected, and many are infected at the time of arrival. In the past it was accepted as a rule that in the first 6 to 8 hours after injury wounds were contaminated, but not infected. This time reference, referred to as the “golden period”, and was based on laboratory studies indicating that bacterial contaminants took more than six to eight hours to reach enough to develop infection. 6 day bite wound Contaminated and infected. Currently, it is recognized that several factors including the type and virulence of the organism, location and type of injury, degree of blood supply, tissue type and resistance to infection, grade and type of pollutants, immune status of the patient, mechanism of injury and the initial wound management among some others, influence the wound to become infected. Systemic antibiotic therapy should be implemented before handling the wound. If treatment is started during the first three hours, we will ensure an adequate level of antibiotic in the secretions present in FACTORS THAT INCREASE RISK OF INFECTION • Prolonged time since the injury • Crush injury (vs sharp injury - knife, glass, etc.) • Puncture Wounds • Bite wounds • Heavily contaminated wounds • Wounds with risk of foreign bodies This treatment should be effective against those bacteria most common in wounds, Staphylococcus, Streptococcus and Escherichia coli. Cephalosporins are a good choice because of its broad spectrum and good tissue penetration. In bite wounds, Pasteurella is the most predominant organism, and amoxicillin or ampicillin could be the antibiotics of choice. In heavily contaminated wounds a combination of antibiotics applied systemic and locally is a better choice. Antibiotics that are to be used locally must be water soluble, non-irritating and must be administered diluted in saline solution. Wound preparation Before surgical treatment it is essential to prepare the wound properly. Patients require sedation or general anesthesia. The type of anesthesia used will depend on the patient’s condition and the estimated duration of the surgical procedure. To prevent further contamination of the wound with hairs and other contaminants, the wound must be protected while the area is being prepared. This is accomplished by applying a sterile hydro soluble gel or sterile gauze soaked in saline covering the wound; or facing the edges of the wound using field forceps or by applying a temporary simple continuous suture. In wounds close to the eyes, you must protect the cornea and conjunctiva instilling an ophthalmic ointment on the eyelid fissure. The use of hydrogen peroxide 5% for cleaning wounds is absolutely contraindicated. Its oxidizing properties are ineffective against anaerobic microorganisms due to the short period of contact, and its activity against aerobic bacteria is extremely low. The main disadvantage of the use of hydrogen REMEVET · Noviembre - Diciembre · AMMVEPE 309
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