Minor Cuts and Wounds

Minor Cuts and Wounds

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Minor Cuts and Wounds Nancy Kleiman, BSP, MBA Date of Revision: August 2014

Pathophysiology

A wound is a disruption in the normal skin structure and functioning due to mechanical trauma and injury. Partialthickness wounds affect the epidermis and outer dermal layers, while deeper, full-thickness wounds penetrate to subcutaneous tissues such as fat, muscle or bone.1 Blunt trauma can produce a superficial bruise or deeper hematoma as a result of leakage of blood from small venules and arterioles.2 Wounds are classified as acute or chronic: Acute wounds can occur from burns, bites, abrasions, scrapes, minor lacerations and punctures. Acute wounds tend to heal quickly with minor treatment. Chronic wounds occur when healing has been delayed or impaired due to various conditions (e.g., immunocompromised patients, diabetics) or have not proceeded through the healing process correctly.1 Wound healing begins at the time of injury and generally proceeds through 3 phases: The first phase is the inflammatory phase which begins at the time of injury and lasts up to 6 days. This phase is characterized by the release of inflammatory mediators resulting in vasoconstriction, redness, pain, platelet aggregation and clot formation. This phase appears as redness, edema and a higher level of drainage from the wound.1 The second phase is the proliferative phase which lasts from 4–24 days depending on the type of wound, cause and depth. This phase is characterized by the formation of new tissue, wound contraction and the formation of new epithelium. The wound remains red and raised.

The third and final phase is the maturation phase. In 4–5 days, collagen forms early scar tissue that holds the wound edges together and strengthens it.2,5 Collagen continues to strengthen the wound beginning 3 weeks after the injury and lasting up to 2 years depending on the type of wound.1 Minor wounds usually heal without scarring. Large or deep wounds may leave a visible ridge or puckering of excess collagen at the healed wound site.

Wound Complications

The most common complications of wounds are infection and scarring.

Infection All wounds are contaminated with bacteria to some extent, and infection is possible if the wound is not dealt with appropriately and promptly. Gram-negative and gram-positive bacteria (including tetanus) and fungi may be involved in wound infections. Infection with Clostridium tetani (found in soil) via a contaminated wound can be fatal. Patients with wounds that are unclean should be given a tetanus vaccination to prevent infection with this bacterium if their vaccination status is not adequate (see Prescription Therapy).1 Minor infection presents with redness, inflammation, tenderness to touch and warmth in the immediate area of the wound. Other symptoms of wound infection may appear as discharge, delayed healing, abnormal odour, wound breakdown and increased pain.1 These symptoms may indicate a more serious infection; referral to a health care professional is recommended. Wound factors that may increase the risk of infection include:1,2 Presence and type of foreign matter in the wound (débridement removes dead or contaminated material

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that can harbor bacteria)

Location of the wound (near a site of potential contamination such as the anal area). One study also found wounds on the lower extremities to be at higher risk of infection.3 Injury to underlying structures such as bone or muscle (deep wound that is difficult and slow to heal and at higher risk of bacterial invasion and infection) Presence of devitalized tissue (increases the risk of introducing bacteria into the wound)

Although historically it was felt that wounds that were closed >12 hours after time of injury were more likely to become infected, there is some evidence that time lapse before wound closure is not as important as previously thought.3 Patient factors related to infection risk include:1,2 Age (epidermis and subcutaneous layer become thinner with increased age)

Underlying medical conditions (diabetes impairs wound healing because of decreased sensation and circulation, peripheral vascular disease)

Malnutrition (deficiencies of protein, zinc and vitamins A and C may slow or impair the healing process) Smoking

Drug therapy (e.g., long-term steroid use inhibits cell growth, chemotherapy medications may affect the immune system and slow healing, blood thinners slow the clotting rate and healing time of wounds)

Scarring Scarring occurs when there is a large deposit of collagen and glycoprotein at the wound site and is a natural part of the healing process. Moist healing environments have been shown to decrease the extent of scarring and improve the healing of wounds by accelerating inflammatory and proliferative phases of repair.4 Discoloration can occur if the area is exposed to the sun, but can be decreased with the use of sunblock for up to 6 months after the injury heals.1 Silicone gels and sheets applied topically hydrate the scar and are used for 3–6 months.6

Goals of Therapy

Provide an environment that optimizes wound healing and prevents cosmetic deformity Prevent infection

Minimize further trauma to the area Minimize patient discomfort

Patient Assessment

Generally, superficial wounds that are fairly small and accompanied by limited bleeding are suitable for self-management. Refer patients to a physician for treatment if they have underlying medical conditions or drug therapy that put them at risk for infection or delayed healing (see Wound Complications). In addition, refer those with large, complicated or chronic wounds. Always refer wounds that continue to bleed, deep puncture wounds, gaping wounds or those that expose fat, muscle or bone, animal bites, wounds with visible foreign material or dirt and any wound causing severe pain (see Figure 1).2 Figure 1: Assessment of Patients with Minor Acute Wounds

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See Burns.

Nonpharmacologic Therapy

Self-treatment of minor wounds includes the following steps: 1. Cleansing the wound: Remove dirt and debris from the wound as soon as possible to prevent infection and promote healing.1 Once debris has been removed, carefully wash the wound with water. Drinkable tap water is as effective for wound cleaning as saline or purified water, with no increased risk of infection or decrease in wound healing noted.7 2. Stopping bleeding: Apply a clean dressing or gauze to the wound area for 10 minutes. If the bleeding does not stop within 10 minutes the patient should seek medical attention. Monitor those on anticoagulants for up to 15 minutes, as the clotting time will be longer, and refer if the bleeding does not stop within that time period. Visible pieces of dirt or other foreign material that remain after irrigation can be gently picked out of the wound with tweezers that have been cleaned with rubbing alcohol, or by brushing gently with clean gauze. These steps protect the wound from infection and tissue destruction and help the wound to heal faster.1 3. Dressing: Choose an appropriate dressing to protect the wound and improve the healing process. Minor cuts, paper cuts or skin cracks can be closed using tissue adhesives or liquid bandage (see Dressings). Larger cuts where the edges won't stay together, the edges are jagged or the wound is deep may need referral for stitches.

4. Débridement: The removal of foreign material such as dead or contaminated tissue from the wound should only be done by a health care professional trained in the area and under sterile conditions.1

Pharmacologic Therapy Nonprescription Therapy Cleansing and Antiseptic Agents Antiseptic use is only appropriate when the risk of infection is high (see Wound Complications). They should be applied only around the wound area, not directly onto the wound (see Table 1). Table 1: Cleansing and Antiseptic Agents

1,8,9,10

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For product selection, consult Compendium of Products for Minor Ailments. Skin Care Products: First Aid. Treatment

Uses

Advantages

Disadvantages

saline solution

Cleansing agent for the initial removal of dirt and debris from a wound.

Not harmful to tissue.

Not always available —drinkable tap water is just as effective for cleansing wounds.7

hydrogen peroxide 3%

An oxidizing agent that has antiseptic, disinfectant and deodorant properties used to clean wounds.

Effervescent action cleanses wounds.

May cause tissue toxicity and impair wound healing through irritation of the tissue and destruction of regenerating epithelium.

Has some mild antibacterial activity.

Has limited bactericidal effect.

Little benefit over soapy water. isopropyl alcohol 70%

iodine

povidoneiodine

Bactericidal in concentrations of 70–90% and used as a disinfectant for wounds and prior to injections.

Can decrease bacteria counts for 20–40 min after contact.

Not to be used on open wounds.

Used as a disinfectant and antiseptic for contaminated wounds, wound bed management and prevention of infection.

Aqueous solution is preferable as it is less irritating and drying than alcohol base.

Stains skin and clothing.

Used as a disinfectant and antiseptic for contaminated wounds and pre-operative preparation of the skin.

Non-irritating to skin.

May be absorbed systemically: use with caution on large areas and if thyroid disorder.

Some fungicidal activity.

Rapid bactericidal activity.

High potential for drying the skin. Irritating to tissue.

May irritate tissue and impair wound healing. May cause allergic sensitization.

Infection and tissue damage increased if used in combination with surfactants. May impair wound healing.

Topical Antibacterials Nonprescription topical antibiotics are recommended in wounds that are at higher risk of becoming infected (see Wound Complications), improperly cleansed wounds or chronic wounds.11 Topical antibiotics have been shown to speed healing and prevent infection in wounds when applied correctly.11 Antibacterial bandages have not been proven to be more effective for wound care than regular bandages and are more expensive (see Table 2).11 Table 2: Nonprescription Topical Antibacterials

9,10

For product selection, consult Compendium of Products for Minor Ailments. Skin Care

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Products: First Aid. Dose/Dosage Forms

Adverse Effects

Apply sparingly 1–3 times daily. Available in ointment and cream, alone or in combination with polymyxin and/or gramicidin to extend spectrum.

Minimal systemic absorption therefore side effects are minimal. Contact allergy with local pruritus, burning, redness possible.

Cross-sensitivity with neomycin reported. Cross-sensitivity with polymyxin possible.

Mainly gram-positive spectrum.

Apply sparingly 1–3 times daily. Available in ointment or cream in combination with polymyxin and bacitracin.

Low incidence of sensitivity. Damages sensory epithelium of nose.

Do not apply to nasal membranes.

Mainly gram-negative including E. coli and Pseudomonas, Enterobacter and Klebsiella species.

Apply sparingly 1–3 times daily. Available in ointment or cream formulations, only in combination with bacitracin and/or gramicidin.

Minimal systemic absorption therefore well tolerated when used topically. Contact allergy uncommon but may cross-react in patients sensitive to bacitracin.

Decreases risk of infection if applied within 4 h to a contaminated wound.

Antibacterial

Action/Spectrum

bacitracin

Mainly gram-positive spectrum. Blocks bacterial cell wall formation.

Activity not impaired by blood, pus, devitalized tissue.

gramicidin

Mechanism of action is unknown.

polymyxin B

Disrupts bacterial membranes by a surfactant-like effect.

Resistance uncommon but can occur with prolonged use.

Comments

Resistance uncommon but can develop with prolonged use.

Prescription Therapy

Tetanus is a potential complication of any wound in those whose tetanus immunization is incomplete or has lapsed.11 Even patients with apparently minor, clean wounds should be referred for a tetanus booster if: their immunization is incomplete (less than 3 doses); they are uncertain when their last tetanus shot was; their last tetanus shot was more than 10 years ago. Patients with dirty or complicated wounds require tetanus prophylaxis if more than 5 years have elapsed since their last tetanus booster.11 Rabies vaccination is a consideration in bites from unprovoked animal attacks, especially where wild animals such as raccoons, skunks, foxes or bats are involved.5 Topical antibiotics are commonly used for the initial treatment of infected wounds. Incidence of resistant strains is increasing with overuse of topical mupirocin and fusidic acid antibiotics. Topical antibiotics should be considered only when medically necessary and used responsibly in order to prevent resistant strains from developing.12

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Oral antibiotics are recommended if an infection persists for more than 2 weeks with topical antibiotic use and correct wound management.1 Oral antibiotics should also be considered for diabetic patients with foot ulcers, impetigo and cellulitis.2 Animal and human bites are routinely treated with prophylactic oral antibiotics. Cat bites are more likely than dog bites to cause infections because cat bites will puncture the skin and bacteria will be introduced directly into the wound. Always refer patients for medical treatment in cases of animal or human bites.

Monitoring of Therapy

A monitoring plan for patients with minor cuts and wounds is provided in Table 3. Table 3: Monitoring Therapy for Minor Cuts and Wounds Sign/Symptom

Monitoring

End Point

Actions

Bleeding

Monitor bleeding: should stop within 10 min (15 min if on anticoagulants).

Bleeding significantly slows or stops within 10–15 min of direct pressure.

Refer to a physician if blood is spurting or significant bleeding persists after 10 min of direct pressure (15 min if anticoagulated).

Infection, e.g., swelling, surrounding redness that is tender to touch, red streaks from the wound, pus or fever

Monitor daily at dressing change for at least 48 h.

No signs or symptoms of infection present at 48 h.

Refer to a physician if signs and symptoms of infection are present at or before 48 h.

Wound healing

Monitor daily at dressing change for 4–14 days (depending on wound type, depth and location).

Normally, healing wounds appear pink or red with tiny opalescent islands of epithelium throughout and no secretions.

Refer to a physician if wound continues to weep, remains raw and red or does not appear to be closing within 2–4 wk.

Suggested Readings

Canadian Association of Wound Care. Available from: www.cawc.net. Dufour A. Wound care. CE lesson. Pharmacy Practice 2007;CE1-8. Health Canada. First Nations and Inuit Health Branch (FNIHB) Clinical Practice Guidelines for Nurses in Primary Care. Adult care. Chapter 9. Skin. Dermatological emergencies. Skin wounds of traumatic origin. Available from: www.hcsc.gc.ca/fniah-spnia/services/nurs-infirm/clini/adult/skin-peau-eng.php#sw1. Singer AJ, Dagum AB. Current management of acute cutaneous wounds. N Engl J Med 2008;359:1037-46.

References 1. Dufour A. Wound care. CE lesson. Pharmacy Practice 2007;CE1-8. 2. Lammers RL. Principles of wound management. In: Roberts JR, Hedges JR, eds. Clinical procedures in emergency medicine. 3rd ed. Philadelphia: Saunders; 1998. p. 533-9. 3. Quinn JV, Polevoi SK, Kohn MA. Traumatic lacerations: what are the risks for infection and has the “golden period” of laceration care disappeared? Emerg Med J 2014;31:96-100.

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4. Korting HC, Schollmann C, White RJ. Management of minor acute cutaneous wounds: importance of wound healing in a moist environment. J Eur Acad Dermatol Venereol 2011;25:130-8. 5. Eastman SR. Basics of wound care. US Pharm 1996;21:91-8. 6. Shields K. Scar reduction products. Pharmacist's Letter 2004;20(200704). 7. Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev 2012;2:CD003861. 8. Pray S. Caring for minor wounds. US Pharm 2006;31:16-23. 9. Sweetman SC, ed. Martindale: the complete drug reference. 35th ed. London: Pharmaceutical Press; 2007. 10. World Wide Wounds. Collier M. Recognition and management of wound infections. Available from: www.worldwidewounds.com/2004/january/Collier/Management-of-Wound-infections.html. Accessed August 7, 2014. 11. Health Canada. First Nations and Inuit Health Branch (FNIHB) Clinical Practice Guidelines for Nurses in Primary Care. Adult care. Chapter 9. Skin. Dermatological emergencies. Skin wounds of traumatic origin. Available from: www.hc-sc.gc.ca/fniah-spnia/services/nurs-infirm/clini/adult/skin-peau-eng.php#sw1. Accessed August 7, 2014. 12. Elston DM. Topical antibiotics in dermatology: emerging patterns of resistance. Dermatol Clin 2009;27:25-31.

Minor Cuts and Wounds — What You Need to Know Tips to treat minor cuts and wounds:

Clean the wound with soap and drinkable tap water to remove dirt and debris from the wound area. Do not use hydrogen peroxide or rubbing alcohol directly on the wound as they can be irritating and interfere with healing. If possible, use running water or water under gentle pressure to clean the wound. A squirt bottle containing water or a large syringe with no needle can be used. Stop the bleeding by applying gentle pressure to the wound using a sterile gauze or clean dressing. Apply pressure for 10 minutes and if the bleeding does not stop refer the patient for further medical treatment. Remove any pieces of dirt or other material (such as glass, metal or gravel) from the wound. Use a pair of tweezers soaked in rubbing alcohol or rub gently with a clean gauze pad.

The dressing should be changed daily or more often if it appears dirty or damp. Some dressings can be left on longer and are designed to be able to monitor the wound without disturbing it. When changing the dressing, monitor for signs of infection such as: red, puffy areas around the wound that are tender to touch red streaks coming from the wound throbbing pain in the wound area

pus (creamy yellowish-grey fluid) in the wound

Other signs of infection include fever, chills or tender lumps or swelling in your armpit, groin or neck. The dressing can be removed after 48 hours if the wound is healing well. CPhA assumes no responsibility for or liability in connection with the use of this information. For clinical use only and not intended for for use by patients. Once printed there is no quarantee the information is up-to-date. [Printed on: 03-03-2016 02:04 PM] RxTx, Compendium of Therapeutics for Minor Ailments © Canadian Pharmacists Association, 2016. All rights reserved

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