|Surgery for Victims of War (ICRC, 1998, 225 p.)|
|9. TREATMENT OF NEGLECTED AND MISMANAGED WOUNDS|
Surgical excision is a more difficult procedure in these wounds. The distinction between viable and non-viable tissue, especially muscle and fascia, is less obvious, and the extent of adequate excision is more difficult to assess than in a fresh wound. But the principles are the same, and excision is directed towards the removal of all non-viable tissue.
Contractility is still the best indication of muscle viability, but this is only valid if the patient is not under the influence of a paralysing anaesthetic agent. Grossly infected fascia is usually shredded and dull grey, while healthy fascia is a glistening white structure. The presence of a bleeding capillary bed, immediately superficial to the fascia, indicates viability. Foreign bodies should be removed if encountered but there is no point in enthusiastically searching for them, as damage may be caused to viable tissue and infection may be spread.
Wounds should be dressed as for routine surgical excision (see chapter 6). Penicillin should be given prophylactically, according to the antibiotic protocol (see chapter 8). No topical antibiotics or antiseptics should be used. Because surgical excision is more difficult in these wounds, there is a higher incidence of persistent infection. In such circumstances, re-excision becomes necessary and the wound should be managed as before. Bacterial culture should be done, if possible, to identify the need for other antibiotics to treat the infection. The indications that a wound is infected are the development of an offensively smelling, moist or overtly pussy dressing and/or the development of pyrexia.
Infected wounds require re-excision, not ward dressings.