A wound is any injury causing an interruption of the normal continuity of
affected structures or tissues, most often the skin. The skin, the outer
integument, is the first line of defense against microorganisms; its loss
facilitates entry of microorganisms into wounds. Wounds are classified as
incised (made with a sharp object that creates a clean cut, such as bites,
knives, scalpel), contused (made by a blunt object that may not break the skin
but may cause significant damage, such as bumping the head when falling);
lacerated (made by an object such as barbed wired that creates a jagged,
irregular cut); puncture (made by a pointed object such as an ice pick or
bullet), or thermal and chemical burns (made by scalds, fires, flammable
liquids, gases, electricity, and chemicals), and decubitus ulcers (bed sores or
- Blunt or penetrating trauma
- Chemical injury
- Thermal injury
- Temperature extremes (e.g., burns, frostbite)
- Ionizing radiation
- Tissue breakdown due to malnutrition or
- Age (e.g., elderly)
- Malnourishment, especially protein depletion
- Trace element deficiencies, especially zinc
- Vitamin deficiencies, especially vitamin C
- Compromised general health
- Location and severity of the wound
- Steroid use
- Radiation and chemotherapy
- Diabetes mellitus
- Weight loss or obesity
|Signs and Symptoms|
- Pain and tenderness
- Possible fever with infection
- Serous, sanguineous, serosanguineous, or purulent exudate
- Loss of function (or mobility)
- Foul smell (in infected wounds
A complete assessment, with a history of the insult event, is essential to
determine the extent and severity of the injury, possible contamination, and
conditions that might complicate the clinical course and treatment. Wound
healing is often divided into three types: (1) first intention healing in which
the edges of a wound are approximated and closed with sutures (e.g.,
laceration), thus scarring is usually minimal; (2) second intention healing in
which the edges of a wound are not approximated and the wound is left open to
granulate (e.g., burns, ulcers), thus scarring is often wide and deep; and (3)
third intention healing in which a wound is left open initially because of
contamination and then subsequently closed surgically. Astute clinical
observation is essential to diagnose possible wound infection, particularly with
- Complete blood count, to monitor leukocytosis (white blood count
should stay between 5,000 and 10,000/mm3), which may herald the
development of sepsis
- Urinalysis, blood urea nitrogen (BUN), and serum creatinine, to
monitor renal function
- Wound cultures, to measure the number of bacteria (<105 organisms
per gram of tissue)
- Sedimentation rate
There are generally four stages of wound healing: (1) vascular response
(immediately for about 10 minutes) characterized by blood vessel constriction,
smooth muscle contraction, platelet aggregation, blood coagulation, followed by
vasodilation, processes that are mediated by histamine release; (2) inflammatory
response (days 1 to 5) characterized by infiltration by neutrophils, monocytes,
macrophages, and lymphocytes to protect against invasion by microorganisms; (3)
proliferative phase (days 5 to 20, depending on the amount of necrotic material
and infection) characterized by formation of granulation tissue, collagen
synthesis, angiogenesis, and wound contraction, processes that are mediated by
cytokines and growth factors; (4) maturation stage (day 20 to resolution, which
could take months or years) characterized by remodeling of scar tissue, the
basic component of which is collagen, a sturdy structural protein found
throughout the body. Scar tissue is only 80% as strong as normal
Treatment depends on the type and severity of the wound. Some wounds are
characterized by a loss of tissue, requiring grafting to repair, and others,
including clean lacerations, result in no tissue loss. It is important to
determine at the outset, based on the history and physical, whether or not the
wound can be closed immediately either by suturing or grafting, or delayed
because of contamination. A contaminated wound can be cleaned sufficiently so
that it can be closed, but infected wounds are never closed until the infection
has been successfully treated. Wounds must be protected from additional
physical, chemical, or bacteriologic complications.
- Analgesics, for comfort especially before wound closure or dressing
- Antiseptics (e.g., povidone iodine), to clean contaminated
- Systemic antibiotics for wound infections; broad-spectrum antibiotics
- Amoxicillin/clavulanic acid (250 to 500 mg orally tid) or
ampicillin/sulbactam (1.5 to 3.0 g intravenously every six hours) for animal
bites (clindamycin or ciprofloxacin can be substituted for penicillin-allergic
- Medicated dressings (e.g., gauze impregnated with topical
antimicrobial agents such as silver sulfadiazine cream, mafenide cream, silver
nitrate), to aid healing and make dressing changes less disruptive to
- Triamcinolone (10 mg/mm3), to ameliorate hypertrophic scar
- Tetanus immune globulin, for tetanus prophylaxis; penicillin (10 to 12
million units intravenously for 10 days); metronidazole (500 mg every 6 hours or
1 g every 12 hours) for tetanus infection
- Exogenous growth factors (e.g., epidermal growth factor [EGF],
transforming growth factor-beta [TGF-beta], platelet-derived growth factor
[PDGF]), to accelerate normal healing
- Surgical excision of burned tissue and wound debridement (removal of
devitalized or contaminated tissue or foreign bodies)
- Skin grafting
- Excision and drainage, for wound abscesses
- Intubation or tracheostomy, for hypoventilation associated with severe
tetanus or pneumonia associated with burn patients
- Splinting, to inhibit contraction, the movement of adjacent skin to
close an open wound; in some parts of the body contraction can cause deformity
|Complementary and Alternative
Homeopathic remedies may provide excellent relief of acute trauma. In
addition, nutrients and herbs can help reduce inflammation, speed healing, and
minimize the risk of secondary infection.
These supplements can also be taken before surgery to reduce healing time.
Lower dose or discontinue when wound has healed.
- Beta-carotene (250,000 IU/day) or vitamin A (50,000 IU/day) promote
healthy scar tissue. These are high doses and should not be taken for longer
than one to two weeks without physician supervision. Reduce dose to 50,000 IU of
beta-carotene and 15,000 to 25,000 IU of vitamin A daily after two weeks.
Vitamin A should be avoided by women who are pregnant or trying to
- Vitamin C (500 to 1,000 mg tid) enhances tissue formation and
- Vitamin E (400 to 800 IU/day) promotes healing when taken internally.
May also be used externally once the acute phase has passed and new skin has
formed. Higher doses may be beneficial for burn victims.
- Zinc (10 to 30 mg/day) stimulates wound healing.
- Bromelain (250 mg tid between meals) is a proteolytic enzyme and an
anti-inflammatory that has been shown to reduce postsurgical swelling, bruising,
healing time, and pain.
- Seacure (3 capsules bid to tid) is hydrolized whitefish protein that
provides absorbable protein necessary for wound healing.
Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or
tinctures (alcohol extraction, unless otherwise noted). Dose for teas is 1
heaping tsp. herb/cup water steeped for 10 minutes (roots need 20
- Turmeric (Curcuma longa) is an anti-inflammatory that
potentiates bromelain. Use the dried extract 250 to 500 mg tid.
- Gotu kola (Centella asiatica) promotes connective tissue
repair, supports normal wound healing, and prevents scar hypertrophy and keloid
formation. For best results, use a standardized extract 60 mg one to two times
daily. For tincture, take 60 drops tid to qid. Gotu kola may also be used
topically as a wash for burns to minimize skin shrinking. Note: in some patients
gotu kola can cause insomnia, agitation, or overstimulation of the sympathetic
nervous system. Reduce dose accordingly.
- Coneflower (Echinacea purpurea) increases macrophage activity.
Goldenseal (Hydrastis canadensis) is an antimicrobial that enhances
healing. Use them together to protect against secondary infection. Equal parts
of tincture may be taken 30 to 60 drops tid to qid.
- Powders of goldenseal, comfrey (Symphytum officinale), and
marshmallow root (Althea officinalis) may be applied topically to enhance
healing and minimize infection. Washes or compresses of cooled tea containing
these herbs may also be used.
- St. John's wort (Hypericum perforatum) oil applied topically
helps prevent postsurgical adhesions and may relieve nerve pain.
- Aloe vera gel applied to burns and wounds provides excellent pain
relief and speeds healing.
- Marigold (Calendula officinalis) and plantain (Plantago
major) aid in healing and can be used topically as salves or creams. These
should only be used in incisional or "clean" wounds. Due to their fast action,
they could encapsulate an infection.
- Granulated or confectioner's sugar applied topically to decubitus
ulcers speeds wound healing. Safe for diabetic
Some of the most common acute remedies are listed below. Acute dose is three
to five pellets of 12X to 30C every one to four hours until symptoms
- Arnica for bruised feeling and grief and/or shock from
- Staphysagria for pain from laceration or surgical
- Symphytum for wounds which penetrate to and involve
- Ledum for puncture wounds
- Urtica for burns
- Hypericum for injuries and trauma to nerves
- Keloid gel (Wala) for
Patients must be monitored for signs of bleeding, discoloration, or swelling
in and around the wound. Fever, increasing pain, and the development of purulent
drainage all indicate the presence of local infection and possible sepsis.
Attention to nutritional status and positioning (to avoid undue pressure on the
wound) are critical to healing.
Most wounds are accidental and often preventable. Wound infection and other
complications can be prevented by careful aseptic technique and prophylactic
- Keloid scar tissue formation is an overgrowth of scar tissue that can
be deforming. A keloid scar often returns even if excised.
- Wound contamination (10% if wounds), for example by Clostridia,
Staphylococcus, Pseudomonas, Proteus, and Klebsiella, can occur in
three stages: simple contamination, cellulitis, and myonecrosis (gas gangrene).
Treatment consists of drainage, surgical debridement, and in severe cases,
amputation. Fungal infections (e.g., Candida, Aspergillus) and herpes
simplex can also compromise wound healing.
- Wound hemorrhage, usually a result of poor technique.
- Burn wound sepsis occurs when microorganisms invade subeschar tissue.
Because most burn wounds are avascular, antibiotics do not adequately suppress
microbial growth. Pneumonia is one of the most common infectious complications
in burn patients.
- Tetanus (Clostridium tetani) occurs most often in mild
penetrating injuries as a result of splinters, thorns, rusty nails, or dirty
abrasions and lacerations, often because these mild injuries are ignored.
Trismus (lockjaw) is pathognomonic. The mortality rates are as high as 30%, but
for patients who recover, recovery is total. Human tetanus immune globulin (TIG)
can prevent tetanus.
Prognosis is dependent on the extent and severity of the initial wound, as
well as of any subsequent infection.
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Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles
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Hardy JD, et al. Hardy's Textbook of Surgery. 2nd ed. Philadelphia,
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Kruzel T. The Homeopathic Emergency Guide. Berkeley, Calif: North
Atlantic Books; 1992:312, 314, 316.
Murray MT. The Healing Power of Herbs. Rocklin, Calif: Prima
Publishing; 1991:184, 185, 207.
Nettina SM. The Lippincott Manual of Nursing Practice. 6th ed.
Philadelphia, PA: J.B. Lippincott; 1996:90-91.
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Copyright © 2000 Integrative Medicine
CommunicationsThis publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
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