54. Wounds
From Primary Surgery
54.1 Preventing infection-the wound toilet
A wound can heal in two ways. Either it can heal by first intention, quickly, with no sepsis, and with the minimum of scarring. Or, it can heal by second intention, slowly by granulation, perhaps with the discharge of pus, and eventually with much scarring. Unfortunately, when you see a wound you often will not know what it is going to do. If you sew it up immediately by primary suture, will it heal elegantly by first intention? Or will it break down and pour out pus?
Answering this question depends on understanding the timing of events as a wound heals after a major injury in a shocked patient. During the first few hours the body's first priority is to maintain the circulation to the patient's brain (53.1) at the expense of that to his less essential organs, including his skin and bones. Meanwhile, the bacteria which have entered his wound have their own time scale. What they do depends greatly on the nature of his wound, and on how much foreign material and dead tissue there is in it, especially dead muscle. Even if there is much debris and dead tissue and conditions favour them, they multiply little in the first 6 hours. From 6 to 12 hours they are beginning to multiply, but after 24 hours they are multiplying fast. If infection is going to occur, it will be established after 24 hours. By about the third day, the body's priorities will have changed, the blood supply to the patient's wound will have increased, and it will be in the ideal state for healing and resisting infection.
You will see the following kinds of wound, depending on the time since the injury, its severity (particularly the amount of dirt, dead tissue, and especially dead muscle present), and the patient's ability to overcome infection.
(1) A wound which presents within the first 6 hours . The challenge before you is to remove all damaged tissue and the dirt by toileting the wound before the bacteria in it can start multiplying. Even a few hours can be important, so don't delay.
(2) A wound presenting at any time with obvious systemic or local signs of infection. These signs don't start for 6 hours, and become more serious the longer the delay. Bacteria are now established in the dead tissue, and are passing into the lymphatics around the wound. If you do too vigorous a toilet, you may spread the infection further, so treat the wound as an infection. Gently remove any slough without disturbing the surrounding tissue, drain the wound, or pack it with dry gauze, or apply a hypochlorite ('Eusol') dressing, and give the patient an antibiotic. This is the delayed wound toilet described in Section 54.5. A day or two later, when you have controlled his infection, you may be able to complete the toilet of his infected wound.
(3) A wound which is more than 48 hours old, without systemic or local signs of infection. By this time the patient has overcome any bacteria that might have been present, so you can safely toilet his wound as vigorously as is necessary.
(4) A wound with much dead tissue in it, which presents between 6 and 48 hours after the injury without any obvious signs of infection. Deciding what to do can be difficult. Should you do a vigorous toilet, or should you merely drain it? The wisest course is to treat it as (2) above and do a gentle toilet, repeating this later if necessary.
Time is critical. If a patient has a severely contaminated wound, he needs a wound toilet, immediately he reaches hospital. Delay is inexcusable. Grossly contaminated wounds and crush injuries are acute emergencies. Every hour's delay makes his chances of an uncomplicated recovery less likely.
| SEVERE WOUNDS ARE ACUTE EMERGENCIES |
After you have toileted a wound, when should you close it? This mostly depends on the interaction of three factors: (1) How much dead tissue or debris there is inside it. (2) Where the wound is. You can close most wounds of a patient's face or hands by immediate primary suture. But in the shaded areas in Fig. 54-1 the risk of infection, and particularly gas gangrene makes immediate primary suture unwise, especially if a wound is heavily contaminated. (3) The time since the injury. You may be able to close a wound immediately if you have toileted it within 6 hours of the injury, before the bacteria in it have started to divide. But if there is much dead tissue or debris, you would be wiser to leave it for delayed primary suture. If you are in any doubt, leave a wound open for delayed primary closure on the third day. The patient will have overcome his infection, and his tissues will be in their most active healing state. His wound will heal by first, not second intention, just as it would do if you sutured it immediately, but it will heal much more certainly.
The common mistakes are: (1) Not to do an adequate wound toilet. (2) Not to leave a wound open for delayed primary closure. Neglect of these things delays wound healing, and may cause traumatic osteomyelitis, or the need for an amputation. There is seldom any indication for suturing any wound in the interval between 6 hours and the third day, with the possible exception of clean knife wounds.
There are two parts to a wound toilet: (1) Do a social cleaning of the wound and the skin round it to wash away bacteria and foreign material. Use soap, a soft nail brush and plenty of water poured in, or saline. You may need many litres, a few spongefuls are not enough. (2) Do a surgical toilet with a scalpel to remove damaged tissue, so that the patient's inflammatory response can get to every part of it. If his wound is large and dirty, toileting it may take you an hour.
Adapt the way you toilet a wound to its severity and its site. Only the severest and most disadvantageously sited wounds in Fig. 54-1 need all the measures described below. At one extreme, a recent clean, incised, knife wound of the scalp needs a social toilet only, and no surgical toilet. At the other extreme you will need to remove much dead muscle from a grossly contaminated wound. Don't hesitate to use a nail brush; it is the best way to remove ingrained dirt, such as occurs when a limb has been dragged along a road.
If there is any contamination, a wound toilet is necessary. For example, if a patient treads on a nail, don't merely give him antibiotics and hope for the best. Instead, excise the puncture wound, curette the track, and leave it open.
You will need these methods: (1) The immediate wound toilet described below, for all wounds which present early, and for those which present late without infection. (2) Immediate primary suture, which can follow it if the indications are right (54.2). (3) Delayed primary closure or skin grafting at 3 days, which should be the rule for severe wounds (54.4), especially if they are contaminated or in dangerous areas. (4) A delayed wound toilet for infected wounds which present late (54.5). (5) Secondary closure, usually by skin grafting, for wounds which are starting to heal by granulation at 10 days (54.6). (6) A method for chronic wounds which are months or years old (54.7).
You cannot prevent bacteria entering a wound at the time of the injury, but you can prevent them entering a wound in the hospital. A common error is not to toilet and suture wounds in a sterile manner. So make sure you do this, and your staff do so too.
| ALL WOUNDS NEED A TOILET
MODIFY THE TOILET TO THE NEEDS OF THE WOUND |
THE IMMEDIATE WOUND TOILET
Here is a general method for most wounds, large or small. Goto other sections for wounds of a patient's scalp (63.6), his face (61.1), or his hands (75.1).
ADMISSION Don't hesitate to admit a patient, even if he has quite a minor wound, especially if it is below his knee, in his buttock or his perineum, or on his abdomen or chest.
X-RAYS If he might have a foreign body or a fracture, X-ray his wound in two planes to locate it. Glass is usually radio-opaque.
INDICATIONS All wounds need some kind of toilet. The simplest toilet (applicable, say, to eyelid wounds) is dabbing on antiseptic after ordinary washing and exploring to remove obvious dirt. Most wounds need more than this, some very much more. The more the dead tissue, the more thorough must be your toilet.
CONTRAINDICATIONS The contraindications to a radical toilet are signs of established infection, such as a foul discharge, lymphangitis, lymphadenitis, or fever. You will not find them in wounds under 6 hours old, so with these wounds you can always do a radical toilet.
EQUIPMENT A minor operation set (4.11), two fairly soft nail
brushes, two skin hooks, soft rubber tubing for a finger tourniquet, or a pneumatic tourniquet. Several litres of clean water, which need not be boiled. Saline is better; make it by adding two level teaspoonfuls of salt to a litre of water. Soap and aqueous chlorhexidine. You will need a good light. If you are
in any doubt, use the main theatre.
TOURNIQUET A tourniquet may sometimes be useful, but don't use one routinely, because it makes distinguishing between living and dead tissue more difficult.
ANTIBIOTICS A thorough wound toilet is more important than any antibiotic. If a patient's wound is severe and particularly if it is heavily contaminated, give him a perioperative antibiotic, as in Section 2.7, before you start his surgical toilet.
ANAESTHESIA Don't hestitate to anaesthetize a patient, even if his wound is quite small. You cannot toilet it adequately if he is conscious.
If he might have injured his nerves and tendons, test them before you anaesthetize him-clinical tests while he is conscious are more reliable than poking about in his wound after he is anaesthetized.
If his wound is large, use regional or general anaesthesia. Ketamine is adequate.
If a patient's wound is small, you can do a nerve block, or you can use a fine needle to inject local anaesthetic solution from his wound into the surrounding tissues. This is particularly useful in children.
THE SOCIAL TOILET OF A WOUND
Do this in two stages before you drape a patient, first the surrounding skin, then the wound.
(1) Pack the patient's wound with a sterile swab to keep it dry while you clean the skin around it with tap water, ordinary soap, and a nail brush. Ask your assistant to pour on more tap water, until the patient's skin is very clean.
(2) Now remove the swab and clean the wound itself. If the dirt is ingrained, use a fresh soft boiled nail brush and gloved or scrubbed hands. You can use a nail brush in a wound. Push it into the dirty tissues of the wound with gentle rotating movements. Don't use vigorous side to side scrubbing movements. Put a basin under the wound, so that your assistant can pour clean water over it continually. Don't immerse it in a basin of water.
THE SURGICAL TOILET OF A WOUND
Paint the skin round the wound with cetrimide or chlorhexidine. Don't use iodine, because this will damage more tissue. Drape it.
CAUTION ! Treat the tissues kindly. Don't grab them with large artery forceps, or swab them violently; this injures them, and makes them less able to resist infection.
Use a scalpel and a pair of forceps to cut away all dirt and ingrained mud etc. Flush smaller foreign bodies out of the wound with sterile Ringer's lactate, saline, or sterile water in a 50 ml syringe, or an ear syringe. You may find pieces of wood, metal, gravel or clothing. Explore the patient's wound. Probing for foreign material is not enough. If necessary, open it widely to look into its depths.
If, for any reason, you have to leave a foreign body, such as deeply embedded bullet, tell the patient so.
Remove all clots and join up all cavities so that they drain readily.
EXTEND THE WOUND, if necessary, in the length of the limb.
If you have to open up a flexure, make an S-shaped incision,
as in Fig. 54-3. If nerves or vessels have been injured, extend
his wound appropriately to reach them.
INJURED TISSUES IN A WOUND
Injured skin. Except on the patient's face cut away 3 mm of the skin margin round the wound, as in A, Fig. 54-4. Don't undermine the skin edges.
Injured fat readily necroses, so cut it back freely until youreach healthy yellow fat which is not bruised.
Injured muscle and fascia. Cut away all torn fascia and open up fascial planes (B). Put retractors in the wound so that you can see inside it. Cut away all dead muscle (C). Dead muscle looks darker and bluish, it does not bleed or ooze when you cut it, and it does not contract when you pinch it with forceps. Snip it away until you reach healthy muscle which contracts and oozes where you cut it. Be radical, dead muscle is an ideal culture medium for clostridia. If you are in doubt as to whether muscle is alive or dead, cut it out! The patient has muscle to spare and will not miss it.
If there are loose pieces of bone which are not attached to periosteum or muscle, they are ischaemic and will die anyway. Remove them. Leave pieces which are still attached to periosteum. Don't scrape live muscle or periosteum from the surface of a bone, because the bone under it may die.
If his bone is exposed in the wound, there are several things you can do:-
If there is muscle nearby, use this to cover the exposed bone. This is usually easy with the femur, the radius or the ulna, because reduction (usually traction) will pull the bone back into the wound. Covering an exposed tibia is not so easy.
If the exposed area of bone is large. you can cover it with moist gauze. Apply sterile saline several times a day, and change the gauze daily. After several months the outer cortex of the bone will slough and you can graft the granulations under it.
If the exposed area is clean, you can graft it with split skin. If this later falls off to leave white dry bone, chisel it away until you reach red cancellous bone, as in Fig. 81-12. You can graft this immediately, but it is probably wise to wait 3 or 4 days for a bed of suitable granulations to form.
If tendons lie exposed see if they are covered by paratenon (the normal fine vascular covering of a tendon). A split skin graft will not take on naked white or dry tendons, but it will usually take if they are still covered by paratenon. If the extensor tendons of a patient's hand are exposed, and there is no such layer, and you cannot refer him, consider doing the groin flap in Section 75-27. If you can refer, him cover his tendons temporarily with split skin and vaseline gauze.
If nerves or vessels are exposed, try to cover them with adjacent tissue, or a simple flap, as in Section 57.11.
If you are not sure if tissue is alive or dead, it is alive if it bleeds or blanches on pressure. If you are still not sure, inspect the wound at 48 hours and remove more dead tissue if necessary. This is wiser than waiting for infection.
SPECIAL STRUCTURES If clinical examination shows that a nerve has been injured, explore it and look at it. If one side is gaping, clean it carefully and suture the epineurium to approximate the ends accurately.
Look elsewhere for the treatment of cut tendons (55.11), cut nerves (55.9), torn arteries (55.6), open fractures (69.7), and open joint wounds (69.8).
RELIEVING TENSION IN THE WOUND If a patient's tissues show any tendency to burst out of his wound, open up his deep fascia longitudinally down the whole length of the muscle compartment involved. This will prevent the compartment syndrome (70.4), and is especially important in the forearm (73.7) and the lower leg (81.14); it may even hasten the union of a fracture.
CONTROLLING BLEEDING FROM A WOUND
If you are using a tourniquet, release it. If bleeding is very severe, see Section 55.1.
If you are not using a tourniquet, bleeding or oozing should start as you cut away dead tissue. If it does not, you have not yet reached viable tissues, so you are not cutting away enough. If the wound is extensive, pack one part of it while you clean another.
Most of the bleeding will probably have stopped by the time you have finished toileting the wound. If larger arteries spurt at you, tie them with silk or linen thread. Tie smaller vessels with fine monofilament. Avoid catgut, especially thick catgut, because it makes a good culture medium.
If necessary, control oozing with packs (3.1), leave them on for 10 or 20 minutes, and apply more if necessary.
SUTURES AND DRESSINGS If you have had to do an extensive
wound toilet, the wound will not be suitable for immediate
primary suture. So pack it with gauze, as in D Fig. 54-4 Aim
for dryness and coolness. Loosely bandage the gauze in place,
making sure the bandages do not restrict the circulation. If the wound is in a limb, raise it (75-1, 81-1).
VENT TETANUS in all wounds, as in Section 54.11.
PREVENT GAS GANGRENE, when necessary, as in Section 54.13. If a patient has a severe muscle wound of his buttock, thigh, calf, axilla, or retroperitoneal tissues, give him penicillin 1.5 megaunits every 4 hours starting immediately after the injury. Or, give him tetracycline.
SPLINTS TO IMMOBILIZE THE LIMB If he has a severe wound of a limb, immobilize it. Skeletal traction is safest. Or, use a plaster back slab. If you use a circular cast, bivalve it immediately, a slit down one side is not enough to prevent swelling. Elevate it
A SECOND SURGICAL TOILET If you see more dead tissue at the time of the delayed closure, toilet his wound again.
| THE COMMON MISTAKE IS FOR A WOUND TOILET NOT TO BE THOROUGH ENOUGH |
54.2 Immediate primary suture
This is the suture of a wound within six hours of the injury,
but it is only safe if the wound is clean, and if it contains no dead tissue. All other wounds are best packed with gauze and left open to see what happens 3 days later (54.4).
When you suture any wound, aim to: (1) Close it at all points and in all planes. Suture it so as to obliterate dead spaces in which blood and exudate can collect as in B, and C, Fig. 54-5. If you allow them to collect, as in F, and G, in this figure, they may become infected, and when they finally organize they will cause a denser scar. (2) Cause as little trauma as you can by using sharp needles and fine sutures. Avoid heavy toothed forceps, blunt knives, and tissue forceps on the skin edges.
IMMEDIATE PRIMARY SUTURE
You have just toileted the wound as in Section 54.1, and have now to decide if it is suitable for immediate or delayed primary suture. For face wounds goto Section 61.1.
INDICATIONS (1) In most parts of the body, primary suture
i s only indicated if a wound: (a) is clean cut, as by a knife or
broken glass, (b) is less than 6 hours old, (c) contains no doubtfully viable tissue, and (d) can be sutured without undue tension. (2) Most wounds of the head, face, and neck, and small
clean wounds on the hands, arms, and scalp, are suitable for immediate primary closure for up to 24 hours because their blood supply is so good. (3) Close all wounds of the dura, and the pleural and peritoneal cavities, by immediate primary suture. If necessary, you can leave the tissues over them for delayed suture.
If all the other conditions apply, except that you cannot bring the skin edges together, you may be able to close the wound by primary skin grafting (57.5).
CONTRAINDICATIONS These are also mostly the indications
for delayed primary suture. They are: (1) Wounds more than 6
hours old, or with dirty or damaged tissue. (2) All severe wounds, crush injuries, gunshot wounds and bites, either human or animal. (3) Any wound in which immediate or delayed primary split skin grafting might be a better way of providing skin cover, for example degloving injuries. (4) Wounds in severely shocked patients whose peripheral circulation is so poor as to seriously weaken wound repair (5) All open fractures (69.7). (6) Most open joint wounds (69.8). (7) Wounds in anyone who is about to be sent on a long journey. (8) Lack of antibiotics, so that you have nothing to give a patient if his wound does become infected. (9) ALL war wounds, especially all missile wounds.
METHODS FOR IMMEDIATE PRIMARY SUTURE
Before you start to close a wound, be sure to control bleeding adequately. Failure to do this is a common cause of infection, necrosis, and breakdown. Close the patient's skin and deep tissues with interrupted monofilament sutures.
If a wound is shallow and the cosmetic result is important, you may be able to use subcuticular sutures as in I, and J, Fig. 61-2.
If the cosmetic result Is not important, use deep interrupted sutures, as in in B, and C, Fig. 54-5. Insert them at 90° to his skin. Put them across the wound, close to the skin edges, so that if they do interrupt the blood supply, they do so in as little skin as possible.
If the wound is deeper, or fat is friable, use interrupted vertical mattress sutures as in A, Fig. 54-5. The large bite closes spaces deep in the wounds, and the small one prevents inversion of the skin edges.
Don't drain the wound; if you expect much discharge, close it by delayed primary suture.
CAUTION ! (1) Don't make the sutures too tight, or put them too close. Exudate should be able to escape from between them. (2) Close all dead spaces.
If you cannot bring the skin edges together, you may be able to undercut them. The level at which you do this is important:(1) In the face, undercut just deep to the dermis (61.1). (2) In the scalp, undercut between the galea and the pericranium. (3) If more than minimal undercutting is necessary in the limbs, do it between the superficial and deep fascia. If you cannot easily bring the skin edges together, graft the wound.
CAUTION ! (1) Undercutting more than 1 cm has its dangers, especially haematoma formation. Split skin grafting may be safer. If you fear infection, mesh it (57.5).(2) Always leave some fat under the skin. If you undermine it too superficially, it will necrose.
POSTOPERATIVE CARE Leave skin sutures in from 4 to 14 days, depending on the thickness and blood supply of the patient's skin. Four days will be enough on the neck or scalp. Ten to 14 days may be necessary on the lower leg, feet, and toes. Remove them earlier if there is increasing pain, pyrexia or pus.
DIFFICULTIES WITH A SUTURED WOUND
If a patient's WOUND BLEEDS WITHIN 24 HOURS (reactionary haemorrhage), a ligature has slipped, or a clot has become dislodged. Bleeding is sudden, and may be massive. Prevent it by tying careful double ligatures on larger vessels.
If his WOUND BLEEDS AFTER 24 HOURS (secondary haemorrhage), sepsis has probably eroded a blood vessel. There may be a small warning bleed before a large vessel bursts. Prevent it by preventing sepsis (2.3).
The treatment for both kinds of haemorrhage is the same. Try to control bleeding with large pressure dressings, such as laparotomy pads. If this fails, take the patient to the theatre, open his wound gently, and tie the vessel. If you cannot find the source of the bleeding, pack it, and remove the pack in the theatre 3 days later. If local pressure fails to control the bleeding, you may very rarely need to tie the vessel proximally (3.3 etc.).
If his WOUND FAILS TO HEAL, or leaves a sinus, think first of a foreign body. If this might be a possibility explore it.
54.3 Some bitter lessons from early suture
Here are two cases where the indications for primary suture were not observed.
| IBRAHIM (6 years) was admitted in severe shock with a gross open fracture of his tibia and a bad laceration of his anus. His wound was carefully toileted, and his leg amputated below his knee. The stump was closed by primary suture and drained. His anus was treated by wound toilet, and a proximal defunctioning colostomy was done. He was given antibiotics, but his amputation stump became so badly infected that his leg had later to be amputated above his knee. |
| MUSTAFA (46 years) had a minor fracture of his fibula, and a wound over the medial side of his ankle, away from the fracture. A wound toilet was done and the wound was stitched, as the doctor who was caring for him said 'to convert a compound fracture into a simple one'. He was then transferred to another hospital and was given antibiotics. Nevertheless, sepsis had spread within his ankle joint so severely that its ligaments sloughed, it fell open and the surrounding bone necrosed. He required five more operations, including sequestrectomy, drainage, and skin grafts. Finally, he was left with an ankylosed ankle. |
What were the mistakes? Both patients had a social toilet and a surgical toilet. The most probable mistake was to suture their wounds too early. The boy would probably not have lost his knee if his original amputation stump had been closed by delayed primary or secondary suture. Sutures inevitably damage the blood supply a little, and kill some tissue, which may tip the delicate balance towards the spread of infection. Both wounds should have been left open, and only closed when they showed signs of healing. Here, by contrast, are some patients whose wounds were left open.
| KAMAU (35 years) had a bad injury to his right hand. He was treated in another hospital but discharged himself when he was told `when the suppuration is over we will amputate your hand'. His hand was indeed seriously injured, with its palm torn open. It was toileted under a tourniquet and bleeding controlled with packs. His wound was then left wide open under a gauze pack. Within 6 days it was granulating well and was ready for grafting. The grafts took and he is now using his hand normally. |
| NJOROGE (25 years) was a bus driver with a severely torn forearm. Lacerated tendons, crushed muscle, bruised torn fat, and damaged ischaemic skin lay ingrained with mud in the depths of his dirty ragged wound. All damaged tissue was cut away, and even some of his tendons, until only healthy bleeding muscle, viable skin, and fat were left in his wound. Packs took 20 minutes to control bleeding, but only a few small arteries needed tying. His wound was left widely open under a gauze dressing, and it, too, was ready for grafting in 6 days. All the grafts took and he is now driving his bus. |
| JACK (51 years) was standing in cattle manure and slurry when he had his legs torn off by a farm machine. Manure was deeply ingrained in what was left of his calf muscles. A social toilet was done using about 15 litres of water. This was followed by a thorough surgical toilet, and below knee amputations, using long flaps and delayed primary suture. Both knee joints were saved and he is now walking on bilateral below knee prostheses. |
Although these are only a few cases, they are examples of a very effective way of managing wounds. A patient usually needs no antibiotics, if he does need one, penicillin is usually enough. If you are in any doubt how to close a wound, wait to see what happens. Delay in closing it will not lengthen a patient's stay in hospital, but an unwise'decision to close it immediately may cause disaster.
IF YOU ARE IN DOUBT, DON'T CLOSE A WOUND IMMEDIATELY
54.4 Delayed primary suture (dps)
This is the most widely useful way of closing a wound. It means closing a wound between the 3rd and the 7th day, usually on the 3rd day. It does not mean waiting for about 10 days until granulations have formed. That is secondary suture.
In nature all wounds heal by granulation, so that immediate primary suture is a recent human invention. Delayed primary suture is thus closer to the conditions under which human tissue evolved. Also, it makes good use of a universally available chemical which is lethal to the anaerobes causing gas gangrene-the oxygen of the air. The main way in which wound care in most hospitals needs changing is: (1) more emphasis on a really adequate wound toilet, and (2) much less on immediate primary closure. Many tragedies, including osteomyelitis and death, result from treatment which is perfect in every way, except that the wound was sutured immediately, when delayed closure would have been wiser. The temptation is great because a wound looks so much tidier when it is neatly sewn up! Unfortunately, dirt, dead tissue and bacteria may all be hidden under a beautifully sutured wound. If a patient arrives in your ward with his wound sutured, and you are not sure about the adequacy of the toilet, or the correctness of immediate primary suture, reopen his wound and look at it. If necessary, leave it open and suture it later.
DELAYED PRIMARY SUTURE
INDICATIONS These are mostly the contraindications to immediate primary suture given in Section 54.2.
You toileted the patient's wound as in Section 54.1, and have decided on delayed primary suture. You have now brought him back to the theatre 3 days later to look at his wound.
If there are no signs of infection, close it by the same methods as for immediate primary suture. Disturb it as little as possible, irrigate it with saline to remove blood clot. Excise any necrotic tissue. Clean its edges, but don't freshen them. If necessary, undercut them (54-6). Bring them together with interrupted monofilament sutures. Apply a pressure dressing and, if necessary, splint his limb as before.
CAUTION ! (1) Control all bleeding. Use packs and avoid ligatures if you can. A haematoma will ruin the chance of success. (2) Don't close the wound under tension. If there are signs of infection, leave the wound open for secondary suture (54.6), or a secondary skin graft. If you have had to excise any necrotic tissue, delay suture for two more days. If you cannot bring the edges together, consider grafting. If the gap is more than 6 to 8 cm you will probably have to graft it. If the wound is on a patient's forearm, hand, or calf, you will have to graft much smaller areas. POSTOPERATIVE CARE If the wound is superficial, leave it for 10 to 12 days. I f it is large and deep, inspect it in the theatre after 5 days. Remove the stitches at 10 to 12 days and start exercises.
54.5 Delayed wound toilet
If a patient presents eight hours or more after the injury with a wound which is already infected, a vigorous wound toilet might spread the organisms further, so you will have to do a more gentle one. Infected operation wounds are described elsewhere (2.8).
SECONDARY WOUND TOILET
INDICATIONS Infected wounds 8 hours or more after the injury.
METHOD If any stitches have already been placed in the
patient's wound, remove them and lay it open. If necessary relieve tension by splitting the fascia. If pus is present, culture it.
If the edges of the wound are acutely inflamed, or there is lymphangitis, lymphadenitis, or fever, give the patient an antibiotic, and make sure you toilet his wound under antibiotic cover, oryou may spread the infection and cause septicaemia. If he has none of these signs, antibiotics are unlikely to be helpful. Remove all necrotic tissue; open up any pockets of pus; remove any infected blood clot, dead bone or foreign bodies.
Be cautious and try not to open up tissue planes at a distance from the edges of his wound. This is especially important if you have no adequate antibiotic.
Eliminate any dead spaces, and provide dependent drainage. Pack the wound with dry gauze or apply a hypochlorite ('Eusol') dressing.
You will probably be able to close the wound some days later by delayed primary suture or by grafting. Immobilize the patient's wound, and elevate his limb (81-1, 75-1).
DIFFICULTIES WITH AN INFECTED WOUND
If a patient's WOUND IS LARGE, and continues to discharge for many days, check his haemoglobin, transfuse him if necessary, and give him a high protein diet.
If his INFECTED, STINKING, DISCHARGING WOUND IS DIFFICULT TO MANAGE, try: (1) Soaking it in a bucket or a bath. (2) Immobilizing it in plaster gutter or splint. Lay it widely open and pack it with gauze. If the wound is not too big, and you need to immobilize a fracture, cover it with a complete cast, and cut a window in it. Make sure the dressings compress it firmly to stop it herniating.
54.6 Secondary suture
If the closure of a wound is delayed beyond 10 days, granulation tissue will grow over it. You will have to close it by secondary suture, rather than by delayed primary suture, although there is no sharp dividing line between these two methods. By now its edges will be indurated and and will be less easy to bring together, so you are more likely to have to graft it. It will also have a growing epithelial edge with an inadequate blood supply. You will need to excise this ingrowing edge, and you may have to prepare the granulations before you can graft them (57.3).
SECONDARY SUTURE
A wound is probably ready for secondary suture when its granulations are favourable by the criteria in Section 57.3. If they are unsuitable, prepare them by the methods in that section.
Apply a tourniquet, where posible. Excise the new epithelium at the edge of the wound, undercut its edges, and gently scrape the granulation tissue off the surface of the wound. Release the tourniquet, and control bleeding.
If you can bring the edges together without too much tension, suture them with a few interrupted sutures. Make sure the sutures go underneath the granulation tissue, not through it.
If you cannot bring the skin edges together, graft the bare area. If sepsis is not completely controlled, be sure to mesh the graft. This is the most usual situation.
54.7 Chronically infected wounds
A chronically infected wound may be months or years old, and so scarred that you cannot bring its edges together by suture. The fibrous tissue at its base may be so dense that you have to excise it first. A chronic tropical ulcer (Chapter 29) is an extreme example of a wound of this kind.
CHRONIC WOUNDS
Don't forget: (1) Neurological causes for chronic ulcers, particularly leprosy (test for anaesthesia and feel for thickened nerves). (2) In Uganda, Buruli ulcer.
WOUND TOILET
Give the patient a bath, clean his wound well with soap and water and shave the skin round it. Examine i t to find out exactly which structures are involved. If there are extensive sloughs or any sequestra, do a thorough wound toilet (54.1).
If the granulations are unfavourable, prepare them, as in Section 57.3 before you then graft them. Change the dressi ngs at least every day, taking care to avoid cross infection. Change them twice daily in the few days before grafting.
Pad the wound and bandage it. A plaster back slab may make the patient more comfortable.
If scar tissue has had time to develop (3 weeks or more), excise it and the subcutaneous layers until you have exposed healthy fascial planes. Wait 3 days for new granulations to form and then graft. You can graft immediately, but the graft will be more likely to take if you wait a few days. A large infective wound will cause the patient to lose much weight. So feed him up (58.12).
CAUTION ! (1) If he is anaemic, treat him. (2) Have you considered the possibility that his ulcer might be tuberculous? These ulcers are often multiple, and there may be a sinus. Antituberculous drugs cure tuberculous ulcers rapidly.
| IF AN ULCER DOES NOT HEAL THINK OF TB |
54.8 Wounds which leave flaps
The simplest wound to leave a flap is a 'V' -shaped laceration. The apex of the 'V' is likely to necrose, so try to replace it without stitching, and warn the patient that healing may be delayed. If a stitch does seem necessary, use the apical stitch in Fig. 54-8.
With larger flaps, you can do three things: (1) You can replace a flap. (2) You can excise and discard it. (3) You can excise it and use it to make a graft. When you treat a wound with a flap you have two decisions to make. Firstly, should you keep the flap? Secondly, what should you do with the fat under it?
Replace a flap if: (1) Its edges bleed. (2) It becomes pale when you press its base and pink again when you let it go. (3) Its base is wider than its length. And, (4) the wound under it is clean. Otherwise, excise it. If you decide to keep it, hold it in place with adhesive strapping rather than sutures.
Fat impedes the diffusion of nutrients from the surface of a wound to the overlying skin of a flap. So trim off any obvious lumps of fat from under a flap as in Fig. 54-9. If a flap is very thick, trim it so that it has a thinner margin and a thicker base which preserves its blood vessels. Make sure that: (1) the patient does not lie on it, and (2) it is uppermost, if it is very thick, so that gravity keeps it in place.
54.9 Degloving or avulsion injuries
These are extreme versions of the injury in the previous section. If a vehicle runs over a patient's limb, it may tear large flaps of skin from the tissues under them. If his skin is hanging loose, as in A, or C, in Fig. 54-10, the diagnosis is obvious, but if it is merely separated from the tissues underneath by a haematoma, as in B, the diagnosis is not so easy. To begin with his skin may look quite normal, and only necrose later. If you are in any doubt, feel it carefully, to make sure it is attatched to the tissues underneath, and look at it again 48 hours later.
If you suture a large piece of degloved skin back in place, it will die, so manage the patient as described below.
| DAMAYANTI (34 years) had a motor accident in which a large part of her
buttock was avulsed, as in A, Fig. 54-10. Fortunately, it had a broad base and did not necrose. She was nursed in the position shown with the flap uppermost. While she lay like this for many weeks, both her arms developed such severe contractures that she was later unable to move them. LESSONS (1) Nurse the patient in a position which will allow gravity to hold a flap in place. (2) Any limb held in an abnormal position for any length of time is liable to develop contractures. So, unless there is some very good reason for not doing so, put all immobilized limbs through their full range of movements each day. |
DEGLOVING INJURIES
If the patient has no skin wound, aspirate the haematoma. Or, incise it, and explore it, to see how much undermining there is, as in B, C, and D, Fig. 54-10. Turn back the skin flaps, and excise or replace them as described below.
If the patient has an open skin wound, excise any grossly damaged skin.
If a flap has a base which is broader than its length, preserve it, trim the fat underneath it as in Fig. 54-9, and reapply it immediately as in E, Fig. 54-10.
If a piece of skin is free, or has a base which is too narrow to let it survive as a flap, excise all the degloved skin and fat and manage the patient's raw wound as described below.
If raw surfaces remain uncovered, take split skin grafts (57.5). Apply them immediately, if the base is favourable (as with muscle). If it is unfavourable, take the grafts, store them (57.8), and cover the wound with dry dressings. At 3 to 5 days when granulations are forming, remove the dressings, and any dead tissue, and apply the stored graft.
CAUTION ! (1) If there is a tyre mark on the patient's skin, he will certainly have a degloving injury under it. (2) Never replace any flap of skin which is longer than its base.
54.10 Missile wounds
Missile wounds, which were only seen by army surgeons in the past, are now common in many of the district hospitals of the developing world. If a patient reaches you alive, you will probably be able to save him, provided his heart or his major blood vessels or his large gut have not been injured. The most important steps are a thorough wound toilet and delayed primary closure.
The higher the velocity of a missile, the greater the damage it does. A low velocity missile, as from a pistol, drills only a narrow track, with little damage around it. A high velocity missile from a modern high velocity rifle, causes an explosion in the tissues with extensive cavitation. Small entry and exit wounds may conceal gross damage inside.
Try to visualize the structures that a missile may have passed through. This is difficult because it may take a very remarkable path, as in Fig. 54-11. If there is no exit wound, look for the missile inside the patient by taking X-rays in two planes.
The wounds from standard rifle bullets are least likely to be infected, because firing will have sterilized them and they do not cause much tissue destruction. Both 'home made', unsterile low velocity missiles, and high velocity missiles causing bursting injuries, are more likely to result in severe infected wounds. Antibiotics have the same rather uncertain role that they have in other wounds (54.1).
de Wind C M, 'Management of missile injuries in a peripheral hospital. Tropical Doctor 1984,14:157-159
MISSILE WOUNDS
See elsewhere for missile wounds of a patient's head (63.6), and his abdomen (66.2).
Resuscitate and anaesthetize him. Leave any existing dressings on until you reach the theatre. Excise the entry and exit wounds, and remove all devitalised tissue.
If the entry and exit wounds are small and there is not much tenderness in between, i t is probably a low velocity injury. You will probably be able to toilet it and save the patient's limb. There is likely to be only a narrow track; cleaning it of all visible debris may be enough. If the track is superficial, unroof it by joining the entry and exit wounds. If it runs more deeply, you may be able to flush it through with saline.
If the exit wound is large, the patient's limb grossly swollen, his bone much fragmented and he is severely shocked, he has probably been injured by a high velocity missile. You you may have to remove much blood clot, dead muscle, and many bone fragments. Prepare for major surgery. Occasionally, you may have to amputate his limb.
Control all bleeding, leave the wound open (except for face wounds which can be closed immediately), and cover it with gauze.
After 3 to 6 days, bring the patient back to the theatre and inspect his wound under general or local anaesthesia. If it looks clean and there are no signs of infection, close it by delayed primary suture. If if is not clean and there is dead tissue present, do a further wound toilet.
CAUTION ! (1) Don't forget tetanus prophylaxis. (2) If you are going to refer a patient, do the necessary early treatment first-reduce a fracture, drain his chest, or explore his abdomen. (3) If removing a missile is going to be more dangerous than leaving it in, leave it. There are many asymptomatic missile carriers.
DIFFICULTIES WITH MISSILE INJURIES
If a patient's BONE HAS BEEN COMMINUTED by the missile, toilet the wound as above, and then leave it unsutured and dressed inide a cast without a window. Consider sending him home. Remove the cast at 4 to 6 weeks. You will probably find a clean healing wound filled with granulation tissue, and a fracture that is uniting clinically and radiologically as it should.
If his THORAX is involved, a thoracotomy may not be necessary, and you will probably not be able to do one anyway.
Drain a haemothorax or haemopneumothorax (65.4 and 65.5). The lung is remarkably resistant to missile injuries.
54.11 Preventing surgical tetanus
The prevention of surgical tetanus depends on: (1) A thorough wound toilet (54.1). (2) The active immunization of everyone in childhood. Further methods at the time of the injury are: (3) Passive immunization to give immediate cover. (4) Active immunization with tetanus toxoid. (5) Antibiotics, usually penicillin, to limit the multiplication of Clostridium tetani. Vary your regime according to the patient's immune state and the nature of his injury by following the methods below.
Toxoid is cheap, widely available, and seldom causes reactions. When they do occur, they are unlikely to be serious, so there is no need to test for sensitivity. The disadvantage of tetanus toxoid is that it does not provide immediate cover. If a non-immune patient has a high risk wound, you can either give him human tetanus immune globulin (HTIG) which is expensive and scarce, but has few side effects, or horse antitetanus serum, which is cheaper, and more widely available, but is more likely to cause serious hypersensitivity.
In practice, passive immunization is much less valuable than the other methods of prevention, and one experienced contributor advised us to leave it out entirely. In a busy hospital, where most patients do not know if they have been immunized or not, you will need a simple regime, so give 0.5 ml of tetanus toxoid to ALL patients with any wound, however small. If you wish, you can combine this with passive immunization of the most dangerous cases only.
The prevention of tetanus is one of the targets of WHO's global EPI program. As more children are immunized and populations become increasingly immune, it should become rarer .
AZIZ (26 years) fell drunk from a second floor verandah and dug both his forearm bones into the earth. His wound was closed by primary suture without a wound toilet. 5 days later he developed tetanus and died. At post mortem a quantity of earth was found in his wounds. LESSON The critical step in preventing tetanus is a thorough wound toilet.
PREVENTING SURGICAL TETANUS
RISKS The risk of tetanus is small in a clean cut, minimally contaminated wound. But it can occasionally follow even a trivial one.
The risk of tetanus is great in burns, deep puncture wounds, injuries of the leg, thigh, buttocks, or axilla; in heavily contaminated wounds, especially crush injuries, and in wounds where there is much injured muscle, especially if they occurred on cultivated land, or if dung has been applied to the wound.
WOUND TOILET Toilet the patient's wound thoroughly and
leave it open.
WHAT TO DO TO PREVENT TETANUS
If you are sure the patient has had adequate tetanus toxoid previously, there are the following possibilities. (Adequate means two injections of toxoid, one of which must have been given during the previous 5 years).
If the risk is small, no further prophylaxis is necessary.
If the risk is great or doubtful, give him a booster dose of toxoid, and antitetanus immunoglobulin or serum (optional), and a megaunit of penicillin.
If he has not had adequate tetanus toxoid previously, assess the risks.
If the risk of tetanus is small, one dose of toxoid is enough.
If the risk is large or doubtful, give him toxoid, and a megaunit of penicillin, and antitetanus immunoglobulin, or serum. Continue penicillin for five days, or until his wound has healed. If his wound occurred more than 6 hours previously, his need for passive immunization is greater. Give him further doses of tetanus toxoid after 6 to 8 weeks and 4 to 6 months to complete his course.
IMMUNIZATION Immunize a patient on the indications given
above. Give the antitoxin and the toxoid with different syringes
in different sites.
Passive immunization If possible, give the patient antitetanus immune globulin of human origin (HTIG) ('Humotet') 500 units intramuscularly. If you don't have this, give him horse antitetanus serum 1500 units intramuscularly.
CAUTION ! If you use antitetanus serum, test him for sensitivity. Inject 0.1 ml subcutaneously into his skin. Wait one hour. If there is any redness or any symptoms, he is allergic and should not have any more.
Active immunization Give an adult tetanus toxoid, 0.5 ml, intramuscularly. One dose gives little immunity, a second dose 6 to 8 weeks later gives more, a third dose 4 to 6 months l ater produces a high level of immunity. Give him another dose 5 years later, and every 10 to 15 years thereafter.
DIFFICULTIES IN PREVENTING TETANUS
If the REGIME ABOVE IS IMPRACTICAL, give all patients with any wound tetanus toxoid. If the risk of tetanus is high, give them prophylactic penicillin also.
| GIVE TETANUS TOXOID TO ALL PATIENTS WITH WOUNDS |
54.12 Treating tetanus
The warning signs that a patient is going to get tetanus are irritability, insomnia, increased muscle reflexes, a sore throat, dysphagia and difficulty starting urination. Tremors and spasm of the muscles near his wound follow. If he is fortunate, his disease remains localized, If it spreads, he has trismus, risus sardonicus, respiratory distress, and perhaps hyperpyrexia. Severe convulsions may follow even minor stimuli. Finally, he dies in opisthotonus with widespread muscle rigidity.
The method which follows is mainly that of Sanders and his colleagues from the Duncan Hospital in Bihar. They showed that the addition of low doses of intrathecal horse antitetanus serum (immune globulin was not available) to the standard regime could reduce the mortality from about 15% to about 5% in a crowded district hospital serving some of the world's poorest people. This regime is more likely to be practicable and may be as effective as attempting to paralyse a patient and ventilate him with intermittent positive pressure respiration (IPPR). If you can keep a patient alive for a month, he will probably recover, but you must sedate him and nurse him well.
Aim to: (1) Remove the source of the toxin by toileting his wound. (2) Sedate him heavily to control his spasms. (3) Nurse him devotedly for as long as is necessary, usually 3 to 4 weeks. (4) Minimize the stimuli which may cause spasms by putting him in a quiet ward and disturbing him as little as possible. (5) Prevent aspiration pneumonia by trying to stop him aspirating his saliva and stomach contents, and by giving him penicillin. This will also prevent Cl. tetani from multiplying.
Treating Tetanus
PROGNOSIS
Grade One The incubation period is over 14 days, trismus i s the patient's only symptom, and comes on over 6 days. Sedation and oral feeding are the main means of treatment. His prognosis is good.
Grade Two The incubation period is 10 to 14 days. Symptoms come on over 3 to 6 days. Moderate trismus is combined with moderate dysphagia, rigidity and spasms. He may need nasogastric feeding, an intravenous drip, and a tracheostomy, or paralysis and IPPR.
Grade Three The incubation period is less than 10 days and symptoms develop over 3 days. Other features are similar to Grade Two but are more severe, or more urgent. If possible, transfer him to a hospital where IPPR and the analysis of blood gases are possible.
CAUTION ! Remember that a patient with tetanus is conscious and aware of all that is going on around him so talk to him and not about him.
CONFIRM THE DIAGNOSIS Examine the patient's nervous
system thoroughly and do a lumbar puncture to exclude
menigitis, encephalitis, and subarachnoid haemorrhage. Don't
assume he has tetanus merely because he is in a surgical
ward. Consider also epilepsy, rabies, and local disease of his
temporomandibular joints. Disturb him as little as possible
when you examine him.
SEDATION Sedate the patient heavily enough to control his
spasms; each patient needs a different dose. Start with chlorpromazine 25 to 50 mg and diazepam 10 mg by intramuscular
or intravenous i njection, or orally, depending on his size and
condition. An average dose is 100 mg 6 hourly. Continue with
diazepam 10 mg, 8, 6, 4, or even 2 hourly, supplemented by
chlorpromazine 25 mg 8 or 6 hourly. Or, use phenobarbitone. If severe spasms cause him great distress, give him
pethidine 50 to 100 mg as required.
CAUTION ! Continue sedation for 5 to 7 days, even if he appears to be improving, or he may relapse.
RESPIRATORY SYSTEM Raise the foot of his bed 30 cm to
help postural drainage, until he can sit up and move about
on his own. Turn him regularly. Suck out his mouth and nose
as required. If necessary intubate him and suck out his
trachea (A 13.2). You will probably find that managing a
tracheostomy is impractical.
THE WOUND should already have been toileted (54.1). If the
toilet has been inadequate, excise the patient's wound widely,
remove all foreign bodies, pus, and clot. Handle it as little
as possible. Leave it open and dress it with diluted hydrogen
peroxide.
CAUTION ! Handling the wound may discharge the toxin in it into the circulation, so, give him antitoxin before you operate.
ANTISERA Ideally, give the patient human tetanus immune
globulin (HTIG) 30-300 U/kg intramuscularly to fix the toxin. Or, exclude hypersensitivity and give him antitetanus serum, 750 units intramuscularly or intravenously once daily for 3 days. Or, give him a single intramuscular dose of 20, 000 units. Intramuscular antitetanus serum is not of great value and regimes vary considerably. Intrathecally as soon as he is adequately sedated, give him one dose of 200 units of antitetanus serum by lumbar puncture. Take this from the smallest ampoule obtainable (1500 units in 1 ml) and measure it with a 'tuberculin syringe.
ANTIBIOTICS Give him benzyl penicillin 1 megaunit intramuscularly every 6 hours. Culture the organisms from his respiratory tract and adjust his antibiotics accordingly.
STEROIDS The value of these are uncertain. Some surgeons
give a patient betamethasone 8 mg initially, preferably
intravenously, and repeat it 12 or 8 hourly.
NURSING Put the patient in the quietest part of the ward.
Manage his bladder by continous catheter drainage with intermittent release (64.16). Prevent pressure sores, stop his
mucosal surfaces drying, and prevent faecal impaction with
suppositories or low enemata. Keep this up for several weeks.
FEEDING If possible, feed him by mouth. Even if he has
trismus he can usually suck fluids through a straw. If
necessary feed him through a nasogastric tube, or drip.
A suitable formula for the drip feed is: glucose 400 g, vegetable oil 100 g, dried skim milk 100 g, water 2.4 litres. This will make about 2.5 I of feed containing 12 MJ (2,900 kcals) or slightly more than an average adult's daily needs. Give him 200 ml 2 hourly.
54.13 Gas gangrene
This is an anaerobic infection of injured muscle caused by various species of clostridia. Suspect that it may occur if: (1) A patient has extensively lacerated muscles, or a missile wound, especially if this involves his buttocks, thighs, or axillae, or his retroperitoneal muscles following an injury to his colon. (2) The blood supply to these parts of his body has been interfered with. (3) His wound is grossly or deeply contaminated with soil.
Gas gangrene is probably developing f he has been progressing satisfactorily, and then suddenly deteriorates. Over a few hours he becomes anxious, frightened, or euphoric. His face (if he is Caucasian) becomes pale or livid, often with circumoral pallor. His injured limb feels uncomfortable and heavy. Although he has recovered from shock and is not bleeding, his pulse rises. It quickly becomes feeble as his blood pressure falls. He vomits.
Don't let these features mislead you: (1) He does not always s mell of death, and even if he does, he may not have gas gangrene. (2) Gas in the tissues is a late sign, and even if it is present, it does not always mean gas gangrene.
One of the patient's muscles may be involved, or more often a group of them, or a whole limb, or part of it. Infection spreads up and down a muscle, and has less tendency to spread from one muscle to another. As infection progresses along a muscle, it changes from brick red to purplish black, as shown in Fig. 54-13. At first the wound is relatively dry; later, you can express from its edges a thin exudate with droplets of fat and gas bubbles, which becomes increasingly offensive. Stain this by Gram's method and look for Gram positive rods.
Prevent gas gangrene like this: (1) Do a thorough wound toilet, especially in all extensive muscle wounds of the buttock, thigh, calf, axilla or retroperitoneal tissues. (2) Give a patient with these wounds 1.5 megaunits of penicillin 4 hourly. If this is not possible, give him tetracycline. If you do a thorough wound toilet and give him penicillin, there is no need for prophylactic antiserum.
Once gas gangrene has developed, don't delay exploring a patient's wound because he is shocked. Radical excision and massive doses of penicillin are his only hope. You will be wise to excise too much muscle rather than too little.
| ANY MUSCLE WOUND IS A POTENTIAL SITE FOR GAS GANGRENE |
GAS GANGRENE
PREVENTION (1) Do a thorough wound toilet (54.1).(2) In high
risk wounds (see above) give the patient penicillin 1.5
megaunits 4 hourly, or tetracycline. Start immediately after
the injury.
DIFFERENTIAL DIAGNOSIS Gas gangrene is not the only
cause of gas in the tissues. Air sometimes escapes into them
in surgical emphysema. In ischaemic gangrene, there is no
toxaemia, unless the gangrenous tissue becomes secondarily
infected. Neither of these should cause difficulty. There are
however two other conditions where the diagnosis is not so
obvious. Both require drainage and penicillin or tetracycline
but neither needs radical muscle excision.
Suggesting anaerobic cellulitis Infection is limited to the patient's subcutaneous tissues. Spread may be rapid and there may be much subcutaneous gas. Sometimes his whole abdominal wall is involved. When you remove the affected tissue, the muscle underneath appears healthy, and bleeds and contracts normally. Remove the necrotic tissue, and drain the wound.
Suggesting anaerobic streptococcal myositis Spreading redness and swelling originating in a stinking discharging wound with Gram positive cocci and pus cells in its exudate. The patient's muscles are boggy and pale at first, then bright red and later pale and friable. The characteristic toxaemia of gas gangrene does not develop. Make radical incisions through his deep fascia to relieve tension and provide drainage.
TREATMENT FOR GAS GANGRENE
NURSING Isolate him from the other surgical patients. If possible, barrier nurse him.
ANTIBIOTICS Give the patient 10 megaunits of benzyl
penicillin daily for 5 days as four 6 hourly doses. Or, give him tetracycline 0.5 g intravenously or 1 g orally every 6 hours. Culture his wound, do sensitivity tests, and if necessary
change his antibiotics. Although clostridia are not sensitive to metronidazole (2.7), some other anaerobic bacteria are, so give it.
ANTITOXIN There should be no need to use this in most wounds. If you give it, do a skin sensitivity test first. Then give him pentavalent gas gangrene antiserum intravenously and
repeat it after 4 to 6 hours.
RESUSCITATION Transfuse him rapidly, and keep a drip running
during the operation.
EXPLORATION Do this in a septic theatre, or even in the
out-patient department, and not where clean cases go for
operation.
Open the patient's wound, enlarge it if necessary, lengthwise in his limb, and cut his deep fascia throughout the whole length of the skin incision.
Excise all infected muscle widely. Remove: (1) Any black crumbling muscle. (2) Any muscle which is swollen and pale and looks as if it has been boiled. (3) Any muscle which does not contract when you pinch it. (4) Muscle which does not bleed. (5) Muscle which contains bubbles of gas. If necessary, remove whole muscles from their origin to insertion, part of a large muscle, or a whole group of muscles. Close his wound later by secondary suture.
AMPUTATION If a patient's limb is disorganized by injury or
infection, amputate it, especially if he shows signs of severe
toxaemia. X-ray it first to see how far the gas has reached.
Amputate under a tourniquet. When you have amputated, his
toxaemia should improve rapidly.
CAUTION ! Close the stump by delayed primary suture, even if you think you are amputating through healthy tissue.
POSTOPERATIVE CARE He may develop septic shock if he
has not already done so (53.4). Expect, and treat as best you
can, the dehydration, vomiting, delirium, jaundice, and anuria
(53.3) that he may develop.
GAS GANGRENE
