Primary closure may not be appropriate for a grossly contaminated or infected wound. Therefore, if closure is a suitable goal, it may be delayed until the contamination or infection is controlled. The wound can be managed short-term as an open wound until it appears healthy. At that time, the wound can be safely closed with minimal risk of complications. The time between initial debridement and final closure vary according to the degree of contamination or infection. Minimally contaminated wounds may be closed after 24–72 hr. Longer periods may be required for heavily infected wounds.
Wounds that are closed >5 days after the initial wounding are considered to be a secondary closure. This implies that granulation tissue has begun to form in the wound before closure.
Open Wound Management
When a wound cannot or should not be closed, open wound management (ie, second-intention healing) may be appropriate. Such wounds include those in which there has been a loss of skin that makes closure impossible or those that are too grossly infected to close. Longitudinal degloving injuries of the extremities are especially amenable to open wound management. Open wound management enables progressive debridement procedures and does not require specialized equipment (such as may be needed with skin grafting). However, it increases cost, prolongs time for healing, and may create complications from wound contracture.
Open wound management is based on repeated bandaging and debridement as needed until the wound heals. Traditional therapy calls for wet-to-dry dressings initially. These dressings help with mechanical debridement at every bandage change. Until a granulation bed forms, the bandage should be changed at least once daily. In the early stages of healing, the bandage may need to be changed as often as twice daily. After granulation tissue develops, the bandage should be changed to a dry, nonstick dressing so the granulation bed is not disrupted. Both the granulation bed and the early epithelium are easily damaged, and disruption of the granulation bed delays wound healing.
More recently, the concept of moist wound healing has emerged. In this technique, wound healing is combined with autolytic debridement to advance wound healing. The use of moist wound dressings keeps white cells healthier, allowing them to aid in the debridement process. Many dressings are available. Alginate dressings are commonly used in the exudative wound to stimulate granulation tissue. Hydrocolloids are used to maintain moisture levels in drier wounds. Classically, moist wound dressings are changed only every 2 days.
Sugar Dressings
Sugar has been used as an inexpensive wound dressing for over 3 centuries. The use of sugar is based on its high osmolality, which draws fluid out of the wound. Reducing water in the wound inhibits the growth of bacteria. The use of sugar also aids in the debridement of necrotic tissue, while preserving viable tissue. Granulated sugar is placed into the wound cavity in a layer 1-cm thick and covered with a thick dressing to absorb fluid drawn from the wound. The sugar dressing should be changed once or twice daily or more frequently as needed (eg, whenever “strike-through” is seen on the bandage). During the bandage change, the wound should be liberally lavaged with warm saline or tap water. Sugar dressings may be used until granulation tissue is seen. Once all infection is resolved, the wound may be closed or allowed to epithelize. Because a large volume of fluid can be removed from the wound, the patient's hemodynamic and hydration status must be monitored and treated accordingly. Hypovolemia and low colloid osmotic pressure are complications that may be associated with this therapy.
Honey Dressings
Honey has also been used for wound dressings over the centuries. Honey's beneficial effects are thought to be a result of hydrogen peroxide production from activity of the glucose oxidase enzyme. The low pH of honey also may accelerate healing. Honey used for wound healing must be unpasteurized, and the source of the honey appears to be a factor in its effectiveness. Manuka honey may be the best option for wound care. The contact layer wound dressings should be soaked in honey before application. The bandage may be changed daily or more frequently as needed.
