A wound is a breach in the normal tissue continum, resulting in a variety of cellular and molecular sequel.
Wounds may be accidental, or as a result of planned surgical interventions of many different types in all the tissues of the body. The term ‘wound’ is generally applied to more superficial forms of tissue damage whereas ‘injury’ is used for damage to deeper structures.
Wounds have a variety of effects on the tissues:
v Mechanical separation of functional structures, such as blood vessels resulting in bleeding. Deformation occurs due to tissue tensions resulting in gaping of skin wounds. (Langer’s lines of minimum skin tension indicate the lines of election for surgical incisions).
v Biological effects commence immediately, as in the resulting inflammatory response from the wounding process per se;
v Secondary effects occur at a latter stage, such as infection.
There are wounds that every doctor may inflict:
v Venepuncture and all forms of vascular access.
v Vaccination and immunization.
v Subcutaneous and intra-muscular injects are wounds in their own right.
v Many forms of access for investigation or treatment, e.g. chest drain, lumbar puncture.
In addition the medical practitioner is likely to encounter common wounds:
v Acute wounds.
- Hand (probing the environment) – cut or crush. Fingertip injuries.
- Face- assaults / road traffic accidents
- Lower limb – high velocity injuries including compound fractures with open skin, and often muscles, wounds in addition to fracture.
- Trunk – stab/penetration injuries.
v Chronic wounds
- Lower leg ulceration is particularly likely in he elderly due to ‘poor tissue vitality’ from arterial insufficiency, venous stasis, diabetes, or steroid medications.
It is necessary for small practitioners to acquire a familiarity with what to do and what to advise in relation to wounds and there sequel scarring. Realistic advice is important and it is an important principle when managing acute trauma not to promise that later treatment will ‘remove’ or improve scarring. Considerable psychological support may require for the wounded patient and predictions should be neither too optimistic, nor too pessimistic.
Clinical features of wounds
The symptoms and signs are
- Bleeding – external/ internal.
- Pain – early due to injury/ later due to complications.
- Loss of function – nerve/ tendon/ bone.
- Inflammation – which adds erythema to many of the above features.
Mechanical effects – The first and foremost indication the patient has of wounding is of pain.
Associated with the pain is a marked degree of distress or anxiety, which is universal through out the anima kingdom and should never be underestimated, superimposed on previous cardiovascular pathology it can even, be fatal.
There may be mechanical loss of functoin such as in division of a tendon, or by a reflex muscle contraction or relaxation mediated through pain.
External bleeding is usual from an open wound and can be profuse where a large vessel has been cut. Closed wounds bruise due to retained bleeding.
Biological effects – Early after wounding the clinical features of the triple response may be apparent and later features of inflammation, heat, erythema, pain (in-addition to the mechanical pain described above), swelling and loss of function.
Systemic effects – Particular wounds may interfere with vital functions, such as chest and head injuries, or penetrating abdominal injuries. Blood loss internally or externally may lead to hypovolumic shock. Later there is a well-documented catabolic response to trauma.
¨ Closed wounds
- Bruise/ contusion
¨ Open wounds
- Puncture wounds and bites
- Abrasions and frictions, burns.
- Bursting type
- Internal organs
- War wounds and gun shot injuries
- Tissue loss
¨ Injuries to special tissues
¨ Pressure sores
It requires no specific management. The patient should be advised that the time required for bruising to clear is extremely variable and in some sites, discolorations may persist for months.
Puncture wounds and bites.
A puncture wound is an open injury in which foreign material and organisms are likely to be carried deeply into the underling tissues. Common causes are standing on a nail or other sharp object. There may be little to see on the surface. Radiological examination may detect metal fragments or glass.
Large foreign bodies should be removed but small particles may be surprisingly difficult to find without a destructive dissection and are better left undisturbed.
Bites are particular type of puncture wound associated with a high incidence of infection presumably from mouth organisms. This is a frequent injury, which presents with a puncture wound over the metacarpal-phalangeal joints. It is important to recognize in the nature of the injury, as the history is often less than harmful.
Abrasions and friction burns.
An abrasion is a shearing injury of skin (due to horizontal force) in which the surface is rubbed off.
Treatment is by cleaning with a scrubbing brush, gently brushing along the grain of the scratch lines. Residual dirt may result in infection or traumatic tattooing. A friction burns is similar but heat from the abrading power has caused burning in addition.
Laceration or cut
Result of contact with sharp object. (The surgical equivalent is an incised wound.). The clinical examination must therefore assess the integrity of all structures in the area: arteries, nerves, muscles, tendons and ligaments. The bone should be assessed by radiography.
The ideal form of management of an incised wound is surgical inspection, cleaning and closure, under appropriate anesthesia, and tourniquet in the case of a limb. All dirt and foreign material must be removed. Organic material is particularly liable to give rise to a severe inflammatory reaction and potentiate infection. The term debridement is in general use to describe the surgical cleaning of a wound.
Crush avulsion injuries
These are open injuries where there has been severe degree of tissue damage. Such injuries occur when hands or limbs are trapped in moving machinery such as in rollers producing a degloving injury.
Treatment of such injuries is to identify the area of devitalized skin and to remove the skin, defat it and reply it is a full-thickness skin graft. Avulsion injuries of hands or feet may require immediate flap over using a one-stage micro vascular tissue transfer of skin and/ or muscle.
The patient coming with wound needs speedy healing, reduction pain, soreness, etc. Most of the patients believe that all the wounds need T.T. injection and ask the Homoeopath to give T.T. injection. It is not necessary to give a T.T. injection to every type of wounds. In Homoeopathy we have medicines against tetanus. Ledum, Hypericum, etc. are very good and effective against tetanus. If we give Ledum, we can prevent tetanus. But the common people don’t know about our medicines in wound management. It is our duty to give information’s about our medicines among the people. Of course the internal medicines alone are not enough to prevent tetanus and sepsis. Through cleaning and removal of the dirt, debris, and foreign bodies from the wound and application of sterile dressing with indicated external medicines are also necessary.
Let us see the type of wounds and their management.
Management of fresh wounds
Here we must give attention to the condition of the patient as well as the condition of the wound.
v Check the conditions of the patient
¨ Is the patient is conscious or not?
- If the patient unconscious, takes steps to bring back the patient in conscious stage. Inhalation of Camphor-Q or Amyl nitrate-Q is very useful to bring back the consciousness.
¨ Is the patient severely exhausted or not?
- If the patient is severely exhausted give Carbo veg directly on the tongue or sublingually.
¨ Is the patient anemic (due to bleeding) or not?
- If the patient is anemic after hemorrhage give China, or Ferrum phos . If severely affected seek expert opinion for blood transfusion.
v Check the condition of the wound.
¨ Bleeding continues:
- Apply cold compress on the affected part.
- If the wound is on the limbs, elevate the limbs above the heart level.
- If the bleeding doesn’t control apply tourniquet.
- Give a dose of Phosphorus directly on the tongue or sublingually.
¨ Remove dirt, and debris from the wounds.
¨ Look for foreign bodies in the wounds. If it is there, it should be removed carefully.
¨ Clean the wounds and surrounding parts thoroughly with weak Hypericum lotion (tincture + distilled water: 1:10)
¨ If the wounds are not deep, and the cut-ends are not wide then apply sterile bandage with Hypericum-Q in full strength. (Full strength seems very effective.)
¨ Change the dressing every day or alternate days according to the conditions of the wound.
¨ Prescribe internal medicines – Calendula , Hypericum , Arnica-. Select the medicine according to the indication.
NB: Care must be taken in every stage. If deep structure or nerves are injured, better to take a surgeon’s help.
Management of the infected wounds.
Patient with infected wounds, we get probably after some days of the incident. Sometimes soreness, swelling, or pus formation is present.
¨ Check the wound thoroughly.
¨ Clean the wound thoroughly with weak Calendula lotion (tincture + distilled water- 1:10).
¨ If the wound is too much dirty, use weak hydrogen peroxide for cleaning.
¨ Remove all dirt and dead tissues from the wound.
¨ Look for any foreign bodies in the wound. If it is there it should be care fully removed.
¨ Never try to suture the infected wounds.
¨ Apply sterile dressing with Calendula-Q or Echinacea-Q in full strength.
¨ Chang the dressing every day or every other day.
¨ Prescribe internal medicines – Myristica, Silicea, Hepar sulp, Calc.sulph. Select the medicines according to the indications.
Short repertory for wound management.
Wounds with profuse bleeding:
Lachesis, Phosphorus, Arnica, Carbo veg.
Arnica, Conium, Ruta, Sulphuric.acid.
Wounds with extravasations:
Arnica, Sulphur, Sulphu.acid.
Incised or cuts
Staphysagria, Arnica, Sulphur, Sulphurc.acid.
Hypericum, Nitric.acid, Carbo veg, Ledum.
Hypericum, Nitric.acid, Carbo veg, Ledum.
Hypericum, Carbol.acid, Ledum, Ruta.
Apis, Ars.alb, Echinacea, Ledum, Pyrogen.
Calc.sulph, Echinacea, Myristica, Hepar, Silicea.