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close this bookMinor Surgical Procedures in Remote Areas (MSF, 1989, 172 p.)
close this folderChapter 1: Wounds - Burns
View the documentDressings
View the documentWounds
View the documentBurns

Dressings

Dressing is a set of procedures for treating a wound. A wound is an interruption in the continuity of the skin secondary to trauma or surgery.

Objectives

· Protection:

- To prevent contamination from the external environment
- To protect against possible trauma

· Cicatrisation:

- To favor tissue regeneration

· Absorption:

- To absorb serous discharge

· Disinfection:

- To destroy pathogenic organisms

· Compression:

- To stop hemorrhage

Warning: A dressing occludes a wound and in certain conditions (humidity, heat) can encourage multiplication of pathogenic organisms.

Equipment

· 1 box of sterile instruments - 1 set of dissection forceps - 1 set of Kocher forceps - 1 pair of scissors
· 1 dressing tray (clean)
· 1 drum of sterile gauze pads
· 1 kidney dish
· Cotton wool (for equipment disinfection only, never use cotton wool directly on a wound)
· Adhesive tape
· Flasks containing antiseptics: chloramine and/or cetrimide-chlorhexidine, and polyvidone iodine (dilution: see table).
N. B. : Never use polyvidone iodine with soaps containing mercurial derivatives.
Solution preparation should be rigorous. Solutions should be renewed every week (every 3 days for chloramine).

General rules of asepsis

· A room should be kept for dressings. It should be carefully cleaned everyday and dressing tables should be disinfected between each patient.
· Use a sterile box of instruments for each dressing, or at least for each patient.
· Always start from the clean area and move to the dirty one.
· Wash hands carefully after each dressing, and after removing bandages or adhesive tape.

Technique

Equipment and instrument preparation

· Cleaning of the dressing tray with cetrimide-chlorhexidine (dilution: see table).

· Removal of the previous dressing

· Removal of bandages and adhesive tape (not the gauze pads)

· Hand washing (clean water + soap)

· Removal of gauze pads, using Kocher forceps

- If the dressing adheres, soak it with sodium chloride solution or an antiseptic.
- Act gently not to remove the granulating epidermis.

Wound examination

· Sutured wound and/or aseptic wound:

- Check the stage of cicatrization if wound is weeping, has a hematoma, or is infected.

· Septic wound:

- Check the nature of secretions and if there are new fleshy pimples.
- A bluish pus indicates the presence of pyocianic (quickly spreading, very resistant bacillus spreading very quickly).
- Look for any signs of lymphangitis.
- Use new forceps after removal of the dirty dressing and the first cleaning of the wound.

Cleaning of the wound

· Use the sterile dissection forceps to remove sterile gauze pads from the container, and place them on the tray.

· To make a sterile sponge fold the pads twice using the Kocher and dissection forceps (as illustrated).


FIGURE

· Pour an antiseptic solution on the pad (infected wound, bures, abcess, ulcers: cetrimide-chlorhexidine; non infected surgical wound: polyvidone iodine (dilution: see table, page 7).

· Clean the periphery of the wound either with a circuler movement, or from top to bottom. Change gauze pads as often as necessary.

· Clean the wound from top to bottom with a new tampon.

· Dry the periphery of the wound and then the wound itself with different gauze pads.

Dressing a wound

· Apply one or several gauze pads to the wound

· Apply strips of adhesive tape: - Perpendicularly to the axis of the limb or the body - Leave the central part free to avoid maceration

N.B.: When sterile disposable material is limited, sterile pads should be reserved for aseptic and surgical wounds.

Frequency of dressings

· Surgical wounds, or non infected sutures: - First day dressing should be well protected - Further dressings, every 48 to 72 h (check the process of recovery).

· Infected wounds: - Dress every 24 h.

· Deep or large burns:

- Dress on the first day, then leave until the 7th day (unless obvious infection)

· Phagedenic ulcers:

- Dress every 24 h, with hospitalization if possible.

Associated antibiotic treatment

As a rule, systemic antibiotic treatment should not be prescribed routinely.

· Deep and soiled wounds, to prevent gas gangrene: procain-penicillin (IM) : 4 or 5 IU per day x 5 days at least.

· Abcess: antibiotic treatment is useless before incision.

· Burns: only if they are infected.

· During conflicts or other disaster relief conditions, where access to health care and patient's follow-up are hazardous, the systematic use of PPF (or procain-penicillin) should be considered.

Wastes

All soiled disposable materials (gauze, coton, dressings, etc.) should be collected and burned daily.


TABLE 1