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Secondary Wound Closure

Sunday, 11 May 2014 00:00 Written by  Gary Griffin

Some wounds are left open to heal, instead of being closed by sutures, staples, or strips. This process is called Secondary Wound Closure; also known as secondary intention and spontaneous healing. In fact, secondary wound closure is the natural process for how our body deals with healing wounds. During secondary wound closure, the body gradually closes and heals on its own, through wound contraction by myofibroblasts. Without getting too far into the “medical weeds”, think of myofibroblasts as the things that conduct tissue repair through regeneration. During secondary closure, the wound heals by layers and ultimately closes itself by rebuilding tissue. 

Secondary wound closure is commonly used in the management of contaminated and infected wounds, where the wound is purposely left open to heal from the inside-out. By leaving the wound open, administrators and patients can properly clean the inside of the wound and remove infected tissues. Secondary wound closure generally involves a wicking material, usually packing gauze, to absorb and remove infection, fluids, and pus. This process is called debridement, and promotes the growth and healing of healthy tissue through the removal of dead, damaged, and infected tissue. The packing gauze also keeps the wound from closing prematurely, which by other means would lock-in unwanted and unhealthy infected tissues inside of the wound, possibly resulting in an abscess.

As with any medical procedure, always keep a patient chart to keep detailed notes on the procedure, medications and the times they were administered, and throughout the post-care period (use our Patient Chart). 

When to Allow Secondary Wound Closure 

  • Inability to receive medical care – One reason to allow secondary closure is due to the patient’s inability to have a wound closed by a trained professional, or if the supplies needed for proper primary closure are unavailable.
  • Wounds that are not treated within 12 hours – If a patient arrives with a wound that has been open for more than 12 hours, there is an increased risk of infection. Therefore, the wound should be allowed to heal through secondary wound closure. However, facial wounds can be closed by primary closure if treated within 24 hours.
  • Highly contaminated wounds – These types of wounds include human and animal bites, gunshot wounds, deep punctures, or wounds that have deeply embedded debris. In these cases, wound irrigation may not be able to properly clean the base of the wound.
  • Wounds with dead space – Dead space, or empty space, occurs when a wound causes a cavity beneath the skin layers. If closed, blood may collect in the dead space, forming a hematoma, increasing the chances of infections and causing further challenges with wound healing. 
  • Wounds with excessive swelling or skin loss – When there is excessive swelling or skin loss, closure may result in the skin being too tight. This reduces blood circulation to the skin edges, causing a low supply of oxygen and nutrients to the skin. This in turn may cause the skin to die; causing a larger wound area than what was initially present.
  • Second-degree burns – Second-degree burns are usually allowed to heal by secondary wound closure.
  • Infected Primary Closure Wounds – Infected wounds that were previously closed using sutures, staples, or strips are re-opened to manage and treat the infection. 

When not to Allow Secondary Wound Closure

  • Wounds that are caused by a fracture that punctures the skin should be closed by primary closure.
  • Wound sites over tendons and joints should be closed by primary closure.

Challenges with Secondary Wound Closure

Secondary wound closure can pose many challenges the patient will have to deal with. These include an extended healing period, being able to access the wound location, pain, and excessive scarring.

  • Extended healing period – It can take weeks to months before the wound heals during secondary closure. This means the patient must also have access to the appropriate amount of medical supplies during this time period.
  • Wound accessibility and self-management – Secondary closure usually involves the “patient” being able to remove and apply dressings to the wound, after primary medical care is received.  If a wound is not accessible by the patient, they will require assistance to properly care for their wound. Additionally, the patient may not have the “stomach” for conducting wound maintenance. Changing bandages may be unbearable due to pain, the appearance of the bandage can be disgusting, and the patient may not be able to deal with the appearance of visible flesh.
  • Pain – The pain associated with open wounds can range from a dull-annoying sensation to one that is very painful. Dressing removal and packing is usually very painful. Therefore, pain medications may be required during the healing process, which may occur over several weeks/months.
  • Scarring– While not a life-threatening issue, wounds left open to heal often have larger scars than if the wound was closed by primary closure.

Secondary Wound Closure Medical Supplies

Medical supplies required for secondary wound closure include packing material, an external dressing, instruments, and expendable supplies required for wound irrigation. It is important that the patient understands the wound may take an extended period to heal; therefore the patient must have access to numerous supplies. This is highly important if you are storing secondary wound closure materials in case of an emergency. It is much cheaper to purchase medical supplies online in bulk, instead of purchasing them from pharmacies and big box stores. The following supplies provide a good baseline for what is needed during secondary closure.

  • Packing Material – Packing material, usually gauze, keeps the wound moist, aiding in the debridement process. This helps the body fight infection, prevents premature healing of the outer skin layer, and protects the wound from further injury. Additionally, packing material helps prevent excessive bleeding in the wound during the early stages of healing. It is recommended to have several different sizes of packing material in your first aid kit.
  • Saline Irrigation Solution – Saline irrigation solution is used to flush the wound between dressing changes, and is used to moisten the packing material. If saline solution is unavailable, you can make your own (See our Saline Guide).
  • Syringe– A syringe is used to flush the wound with saline, before applying new packing materials into the wound.
  • Outer Dressing – The outer dressing protects the skin around the wound from further injury, absorbs drainage, and helps keep the wound clean from outside contaminants. Use non-adherent dressings to keep the bandage from sticking to the wound area. Additionally, dressings should be sized to the wound (non-adherent bandage, abdominal pad).
  • Tape – Tape is used to secure the outer dressing to the skin.
  • Probe – Probes are used to insert packing material into the wound, and should be a clean object or a sterile Q-Tip applicator.
  • Tweezers – Tweezers are used to remove packing material from the wound, and if clean/sterile can be used for wound packing.
  • Gloves – Gloves protect both the patient and the administrator.
  • Isopropyl Alcohol – Used to clean adhesive residue from around the wound.
  • Plastic Bag / Hazmat Bag – Place used packing material and dressings in the bag, and dispose the bag after use.

Prepare the Work Area

Before cleaning a wound, packing a wound, or removing packing from a wound, you should establish a clean work area. Bandages should be sterile, and the instruments for cleaning and packing need only to be clean. However, it is recommended to use sterile supplies whenever possible. Find a table so that you can layout your supplies, which should be cleaned using soap and water. After cleaned, ensure to wipe excess water from the table or let air dry. If the table or other surface cannot be washed using soap and water, place a clean towel or drape over the area to be used, and layout your supplies on the towel/drape. Before removing the supplies from packaging, wash your hand with soap and water. Hand washing should be conducted before and after each step.

Clean the Wound

Wound Irrigation Supplies

(1) Syringe, 20cc

(1) Saline Solution, Sterile (100ml or more)

(1) Nitrile Gloves, Pair

(1) Alcohol Pad

(2) Gauze Pad, 2x2

Before packing a wound, you should irrigate the wound using saline. The flushing process should be thorough; however you do not want to use excessive pressure/force when flushing the wound. Excessive pressure may destroy newly created tissue inside of the wound. A 20ml syringe is ideal for the flushing process. If you do not have sterile saline, you can make your own (See our Saline Guide).

You can use isopropyl alcohol on the outside of the wound to remove any sticky residue left over from medical tape. Do not allow alcohol to enter the wound, since it will cause discomfort and may kill new tissue.

Directions

  1. Wash hands thoroughly using soap and water.
  2. Put on a clean pair of gloves.
  3. Place a catchment basin under the area to be cleaned. Alternatively, you can irrigate the wound over a sink.
  4. Using a syringe, draw saline into the syringe.
  5. Place the syringe above the wound, or the tip slightly inside of the wound, and press down on the plunger to force saline into the wound. Remember, do not use excessive pressure.
  6. Repeat the wound irrigation process a minimum of three times (60ml).
  7. Use gauze pads to dry the area.
  8. Discard used supplies.

 

http://tinyurl.com/q6apwn2

Pack the Wound

Packing Supplies

(1) Nitrile Gloves, Pair

(1) Packing Material (sized to wound)

(2) Q-tips, Sterile

(1) Outer Dressing (sized to wound)

(1) Tape

(1) Sterile Drape (Optional)

(1) Saline Solution, Sterile (use remaining saline from cleaning procedure)

The wound should be packed using sterile packing material. Most packing materials come in strips, usually 5 yards long. Once the container is opened, the strip loses its sterility. However, wound packing does not require sterile materials, since the wound itself is not sterile. The packing material should be clean. So, once the container is opened, give it to the patient for future dressing changes.

Directions

  1. Gather supplies to include gloves, saline, gauze pads or other packing materials, tweezers and/or probe, outer dressing, and tape. Optionally, have a clean basin or container to moisten gauze/packing materials. Optionally, you can use a sterile drape to provide a clean work area.
  2. Wash hands thoroughly.
  3. Optional: (1) Open and place a drape to create a clean work area. (2) If using packing strips, cut the strip to the desired length.
  4. Moisten packing materials using saline, but do not soak. Remove excess saline by gently squeezing.
  5. Unfold the packing materials into a single layer.
  6. Pick up one end of the packing materials with your fingers or tweezers, and place the other end into the corner of the wound. Do not allow the packing materials to come in contact with dirty areas; keep elevated or on a clean work zone.
  7. Pack the gauze into the wound using clean tweezers, a probe, or sterile Q-tips. You should create layers of the packing material by folding the material inside of the wound.
  8. Ensure you use enough packing material to fill the entire wound area, but do not pack too tightly.
  9. Ensure that all gauze ends remains at the top of the wound. The end will allow the administrator or patient to easily find and pull out the packing, at the next change.
  10. Repeat if more than one packing material is needed, and remember to place the end at the top of the wound. If excess material is remaining, either cut the material or fold neatly at the top of the wound.
  11. Using non-adherent sterile gauze, or other outer dressing, place over the entire wound area. Using tape, cover all sides of the external dressing.
  12.  Using the patient’s chart or your notes, identify how many packing materials have been placed inside of the wound, and the time the procedure was conducted.

 

http://tinyurl.com/nwh3yc4

Remove the Dressings

Removal Supplies

(1) Nitrile Gloves, Pair

(1) Gauze Pad, 4x4

(1) Plastic Bag

To continue the healing process, dressings should be changed regularly. To change a dressing, use the following procedure.

Directions

  1. Gather supplies to include gloves, a plastic bag (to discard dressings and packing materials), and gauze pads (for cleaning the outside of the wound).
  2. Wash hands thoroughly.
  3. Using the patient’s chart or your notes, identify how many packing materials have been placed inside of the wound.
  4. Put on clean gloves. The gloves do not need to be sterile.
  5. Remove the outer dressing, while pressing down on the skin closest to tape edges. If the outer dressing is stuck to the wound, pour saline on the dressing, let it sit for 2-3 minutes, and then remove dressing. Discard the dressing by placing it inside of the plastic bag.
  6. If more than one packing is present, remove the one closest to the top. Gently pull the tail, and completely remove from the wound. Repeat the process if more than one packing is inside of the wound.
  7. Place used packing materials inside the plastic bag.
  8. A gauze pad can be used to absorb any blood that comes out with the packing materials.
  9. Place used gauze in the plastic bag.
  10. Remove gloves and place in the plastic bag. Discard the plastic bag.
  11. Wash hands thoroughly.

 

http://tinyurl.com/ouww8dh

(Note: While this video does not show proper procedure, specifically washing of hands and use of gloves for bandage removal, it gives a realistic perspective on home-based wound care. Additionally, this video demonstrates using smaller gauze to pack a wound.) 

Secondary Closure Time Table

There is no clear timeline for how long it will take for a wound to close on its own. Small wounds can heal in a matter of days, while large ones could take months. The patient’s health also plays a big role. Therefore the clean, pack, and remove cycle will continue until the wound is healed. Remember, secondary wound closure may require a large quantity of supplies. As for a timeline, these three rules should help you out.  

Rule 1: Two times a day – The dressings are changed two times a day, every 12 hours, while there is drainage from the wound. Once drainage stops, and the wound appears to be clean, the dressings can be changed once daily.

Rule 2: It may take a while – During secondary closure, the wound will heal from the base of the wound up. Also the sides of the wound will heal in. You should continue changing the dressings until the wound fills on its own, using less packing material each time. The time required for closure will depend on the depth and size of the wound, and how the patient’s body reacts to the process.

Rule 3: Antibiotics – There are several studies which suggest the administration of antibiotics will not reduce infection rates during secondary wound closure. However, antibiotics will add some protection against infection. This is a personal choice that you will have to make, but if you have them use them. Antibiotics for skin infections include:

  • Cephalexin
  • Erythromycin
  • Amoxicillin / Calvulanate (Note: If plain Amoxicillin is all that you have, it is better than nothing. Some staph bacteria is resistant to plain Amoxicillin)
  • Ciprofloxacin

When to be Concerned

  • Temperature over 101.5 F
  • Chills
  • Increased redness around the skin
  • Increased swelling of the wound area
  • Increased tenderness or pain inside of the wound (remember the dressing change process can be painful, and should not considered as increased pain)

Note: Antibiotics may resolve these issues.

Sources

Open Wound Care: Discharge Instructions

Discharge Instructions for Wound Care

Last modified on Sunday, 11 May 2014 03:01
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