A wound occurs when the integrity of any tissue is compromised (e.g. skin breaks, muscle tears, burns , or bone fractures ). A wound may be caused by an act (such as a gunshot, a fall, or a surgical procedure), by an infectious disease, or by an underlying condition.
Types and causes of wounds are wide ranging, and healthcare professionals have several different ways of classifying them. They may be chronic, such as the skin ulcers caused by diabetes mellitus ; or acute, such as a gunshot wound or animal bite. Wounds may also be referred to as open, in which the skin has been compromised and underlying tissues are exposed, or closed, in which the skin has not been compromised, but trauma to underlying structures has occurred (e.g. a bruised rib or cerebral contusion). Emergency personnel and first-aid workers generally place acute wounds in one of eight categories:
- Abrasions. Also called scrapes, they occur when the skin is rubbed away by friction against another rough surface (e.g. rope burns and skinned knees).
- Avulsions. These occur when an entire structure or part of it is forcibly pulled away, such as the loss of a permanent tooth or an ear lobe. Explosions, gunshots, and animal bites may cause avulsions.
- Contusions. Also called bruises , these are the result of a forceful trauma that injures an internal structure without breaking the skin. Blows to the chest, abdomen, or head with a blunt instrument (e.g. a football or a fist) can cause contusions.
- Crush wounds. These occur when a heavy object falls onto a person, splitting the skin and shattering or tearing underlying structures.
- Cuts. These slicing wounds are made with a sharp instrument, leaving even edges. They may be as minimal as a paper cut or as significant as a surgical incision.
- Lacerations. Also called tears, these are separating wounds that produce ragged edges. They are produced by a tremendous force against the body, either from an internal source as in childbirth , or from an external source like a punch.
- Missile wounds. Also called velocity wounds, they are caused by an object entering the body at a high speed, typically a bullet.
- Punctures. These deep, narrow wounds are produced by sharp objects such as nails, knives, and broken glass.
Wounds are very common. Nearly everyone has had a wound of one type or another. Minor wounds are especially common in childhood because children engage in so much rough-and-tumble play .
Causes and symptoms
Acute wounds have a wide range of causes. Often they are the unintentional results of motor vehicle accidents, falls, mishandling of sharp objects, or sports-related injury. Wounds may also be an intentional result of violence involving assault with weapons, including fists, knives, or guns.
The general symptoms of a wound are localized pain and bleeding. Specific symptoms include the following:
- An abrasion usually appears as lines of scraped skin with tiny spots of bleeding.
- An avulsion has heavy, rapid bleeding and a noticeable absence of tissue.
- A contusion may appear as a bruise beneath the skin or may appear only on imaging tests. An internal wound may also generate symptoms such as weakness, perspiration, and pain.
- A crush wound may have irregular margins like a laceration; however, the wound will be deeper and trauma to muscle and bone may be apparent.
- A cut may have little or profuse bleeding depending on its depth and length. Its even edges readily line up.
- A laceration too may have little or profuse bleeding, the tissue damage is generally greater, and the wound's ragged edges do not readily line up.
- A missile entry wound may be accompanied by an exit wound, and bleeding may be profuse, depending on the nature of the injury.
- A puncture wound's depth will be greater than its length; therefore, there is usually little bleeding around the outside of the wound and more bleeding inside, causing discoloration.
When to call the doctor
A child who has become impaled on a fixed object, such as a fence post or a stake in the ground, should only be moved by emergency medical personnel. Foreign objects embedded in the eye should only be removed by a doctor. Larger penetrating objects, such as a fishhook or an arrow, should only be removed by a doctor to prevent further damage as they exit.
Many times wounds can be treated at home; however, additional medical attention is necessary in several instances. Wounds which penetrate the muscle beneath the skin should be cleaned and treated by a doctor. Such a wound may require stitches to keep it closed during healing. Some deep wounds that do not extend to the underlying muscle may only require butterfly bandages to keep them closed during healing. Wounds to the face and neck, even small ones, should always be examined and treated by a doctor to preserve sensory function and minimize scarring. Deep wounds to the hands and wrists should be examined for nerve and tendon damage. Puncture wounds may require a tetanus shot to prevent serious infection. Animal bites should always be examined and the possibility of rabies infection determined.
Wounds that develop signs of infection should also be brought to a doctor's attention. Signs of infection are swelling, redness, tenderness, throbbing pain, localized warmth, fever , swollen lymph glands, the presence of pus either in the wound or draining from it, and red streaks spreading away from the wound.
Even with the loss of less than one quart of blood, a child may lose consciousness and go into traumatic shock. Because this condition is life-threatening, emergency medical assistance should be called immediately. If the child stops breathing, artificial respiration (also called mouth-to-mouth resuscitation or rescue breathing) should be administered. In the absence of a pulse, cardiopulmonary resuscitation (CPR) must be performed. Once the child is breathing unassisted, the bleeding may be attended to.
In cases of severe blood loss, medical treatment may include the intravenous replacement of body fluids. This treatment may be infusion with saline or plasma or a transfusion of whole blood.
A diagnosis is made by visual examination and may be confirmed by a report of the causal events. Medical personnel will also assess the extent of the wound and what effect it has had on the patient's well being.
Treatment of wounds involves stopping any bleeding then cleaning and dressing the wound to prevent infection. Additional medical attention may be required if the effects of the wound have compromised the body's ability to function effectively.
Stopping the bleeding
Most bleeding may be stopped by direct pressure. Direct pressure is applied by placing a clean cloth or dressing over the wound and pressing the palm of the hand over the entire area. This pressure limits local bleeding without disrupting a significant portion of the circulation. The cloth absorbs blood and allows clot formation. The clot should not be disturbed, so if blood soaks through the cloth, another cloth should be placed directly on top rather than replacing the original cloth.
If the wound is on an arm or leg that does not appear to have a broken bone, the wound should be elevated to a height above the child's heart while direct pressure is applied. Elevating the wound allows gravity to slow down the flow of blood to that area.
If severe bleeding cannot be stopped by direct pressure or with elevation, the next step is to apply pressure to the major artery supplying blood to the area of the wound. In the arm, pressure would be applied to the brachial artery by pressing the inside of the upper arm against the bone. In the leg, pressure would be applied to the femoral artery by pressing on the inner crease of the groin against the pelvic bone.
If the bleeding from an arm or leg is so extreme as to be life-threatening and if it cannot be stopped by any other means, a tourniquet may be required. However, in the process of limiting further blood loss, the tourniquet also drastically deprives the limb tissues of oxygen. As a result, the patient may live but the limb may die.
Dressing the wound
Once the bleeding has been stopped, cleaning and dressing the wound is important for preventing infection. Although the flowing blood flushes debris from the wound, running water should also be used to rinse away dirt. Embedded particles such as wood slivers and glass splinters, if not too deep, may be removed with a needle or pair of tweezers that has been sterilized in rubbing alcohol or in the heat of a flame. Once the wound has been cleared of foreign material and washed, it should be gently blotted dry, with care not to disturb the blood clot. An antibiotic ointment may be applied. The wound should then be covered with a clean dressing and bandaged to hold the dressing in place.
In addition to the conventional treatments described above, there are alternative therapies that may help support the injured person. Homeopathy can be very effective in acute wound situations. Ledum ( Ledum palustre ) is recommended for puncture wounds (taken internally). Calendula ( Calendula officinalis ) is the primary homeopathic remedy for wounds. An antiseptic, it is used topically as a succus (juice), tea, or salve. Another naturally occurring antiseptic is tea tree oil ( Melaleuca spp.), which can be mixed with water for cleaning wounds. Aloe ( Aloe barbadensis ) can be applied topically to soothe skin during healing. When wounds affect the nerves, especially in the arms and legs, St. John's wort ( Hypericum perforatum ) can be helpful when taken internally or applied topically. Acupuncture can help support the healing process by restoring the energy flow in the meridians that have been affected by the wound. In some cases, vitamin E taken orally or applied topically can speed healing and prevent scarring.
Without the complication of infection, most wounds heal well with time. Depending on the depth and size of the wound, it may or may not leave a visible scar. Individuals with certain underlying diseases such as diabetes mellitus may have more difficulty healing.
Most actions that result in wounds are preventable. Injuries from motor vehicle accidents may be reduced by wearing seat belts and placing children in size-appropriate car seats in the back seat. Sharp, jagged, or pointed objects or machinery parts should be used according to the manufacturer's instructions and only for their intended purpose. Firearms and explosives should be used only by adults with explicit training; they should also be kept locked and away from children. Children engaging in sports , games, and recreational activities should wear proper protective equipment and follow safety rules.
Children need to be instructed not to pick at scabs, because it slows the healing process and increases the risk of infection. Wounds tend to occur often during childhood, but most of them are minor and can successfully be treated at home.
Abrasion —Also called a scrape. The rubbing away of the skin surface by friction against another rough surface.
Avulsion —The forcible separation of a piece from the entire structure.
Butterfly bandage —A narrow strip of adhesive with wider flaring ends (shaped like butterfly wings) used to hold the edges of a wound together while it heals.
Cut —A slicing wound made with a sharp instrument, leaving even edges.
Laceration —A cut or separation of skin or other tissue by a tremendous force, producing irregular edges. Also called a tear.
Plasma —A watery fluid containing proteins, salts, and other substances that carries red blood cells, white blood cells, and platelets throughout the body. Plasma makes up 50% of human blood.
Puncture —An injury caused by a sharp, narrow object deeply penetrating the skin.
Tourniquet —Any device that is used to compress a blood vessel to stop bleeding or as part of collecting a blood sample. Phlebotomists usually use an elastic band as a tourniquet.
Traumatic shock —A condition of depressed body functions as a reaction to injury with loss of body fluids or lack of oxygen. Signs of traumatic shock include weak and rapid pulse, shallow and rapid breathing, and pale, cool, clammy skin.
Whole blood —Blood which contains red blood cells, white blood cells, and platelets in plasma.
Baranoski, Sharon, et al. Wound Care Essentials: Practice Principles. Philadelphia: Lippincott Williams & Wilkins, 2004.
Brown, Pamela A., et al. Quick Reference to Wound Care. Sudbury, MA: Jones & Bartlett Publishers, 2005.
American Medical Association. 515 N. State Street Chicago, IL 60610. Web site: http://www.ama-assn.org .
Tish Davidson, A.M. Bethany Thivierge