Beyond skin tears: Clinical pearls for approaching post-acute traumatic wounds

Nurse trims the bandage on a traumatic wound on a patient’s leg.

Treating traumatic wounds is challenging in any setting. While they’re not as common in the post-acute care setting, we do see traumatic injuries and it’s important to be familiar with how to best treat them. The most common traumatic wounds in the post-acute care environment are skin tears. That’s because elderly people are more prone to this type of injury. However, we do see other injuries such as falls, lacerations, punctures, abrasions, crush injuries, blunt trauma, and more— especially in the LTAC (long term acute care) setting.

When it comes to managing traumatic wounds, every wound has a story. Factors such as the mechanism of injury, the size and depth of damage to tissue, viability of remaining tissue, and pre-existing comorbidities all make each wound unique. This means how we treat each wound should also be unique, depending on the needs of the wound and the patient. However, generally, there are 3 steps to take when assessing and managing any type of post-acute traumatic skin wound:
3 Steps to Treating Traumatic Wounds

1 Clean

The first step in approaching a traumatic wound is to “clean it up,” so to speak. These wounds are dirty, uneven, and often contain non-viable tissue whose area and depth can get worse over time. It’s most important to remove non-viable tissue, since it can harbor bacteria, induce inflammation, and prevent development of healthy granulation tissue within the base of the wound bed.

Luckily there are quite a few methods to go about this. Enzymatic and autolytic debridement agents are frequent go-to treatments, as are mechanical and sharps debridement techniques.

2 Control

Next, control the risk of infection. Since we know these wounds can frequently be dirty, they are often at high risk for infection. Many of these wounds will also remain open to heal via secondary intention and contain non-viable tissue, which can make them susceptible to bacterial colonization and growth. Start by utilizing topical methods like wound cleansers. If the wound is at higher risk for infection, consider bacteriostatic/bactericidal agents or treatments that prevent the aggregation of planktonic bacteria and disrupt/remove biofilms.

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3 Close

Finally, determine the best method for closure. Ideally, closing all wounds by primary intention would be ideal, but that’s not always an option. If an area can be cleaned completely and has enough remaining viable tissue to reapproximate deeper layers and allow for closure of the epidermal layer, healing by primary intention with suture or staples is preferable. However, many traumatic wounds will need to heal by secondary or even tertiary intention. Secondary intention allows wounds to heal from the base-up and the outside-in when primary closure isn’t possible. Most trauma wounds fall into this category. While these wounds will be at greater risk for infection throughout healing, if the wound is cleansed appropriately and given extra care and treatment you can reduce that risk. Closure by tertiary intention (or delayed primary closure), is not typical, but can be used when primary closure is the goal— allowing time for factors, such as swelling, to subside.

In closing, traumatic wounds can be challenging to treat throughout the healing process, especially in the elderly and more medically complicated population. But laying out a plan and maintaining the best possible healing environment can make a huge difference when it comes to managing this type of wound.

Courtesy of Bryan Galloway, MD, of Medline Industries, LP

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