The management of acute wounds commonly seen in community pharmacy

Case scenario

Ram, an 18-year-old male, comes into the pharmacy limping. You approach him and ask if there’s anything you can do to help. He tells you that he cut the bottom of his foot as he jumped into a rock pool. He has rinsed his wound under tap water and asks if there’s anything else you can recommend for first aid. You invite him into a private consultation room and ask for permission to assess his wound. You ask for his medical history, including tetanus vaccination status, which is up to date, and he tells you he has no medical conditions.

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.

Introduction

Wounds may be acute or chronic. An acute wound is one where the healing typically proceeds in a timely and orderly reparative process, resulting in sustained restoration of anatomical function and functionality.^1–3 All chronic wounds begin as acute wounds, but instead of progressing through the normal wound healing phases of haemostasis, inflammation, proliferation, and maturation, they become stagnant or prolonged in the inflammatory phase.^3,4 Contributing factors of healing impairment include intrinsic and extrinsic factors such as underlying pathology, malnutrition, medications, inappropriate dressing choice, diabetes, thrombocytopenia, peripheral vascular insufficiency, psychological status, body build, age, prior radiation and/or venous insufficiency.^1,3

Pharmacists are uniquely positioned to be the first port of call when it comes to acute wound care management, due to the availability, abundance and timely accessibility of the profession.

Acute wounds commonly seen in the pharmacy include^5–9:

• abrasions
• lacerations/cuts
• minor burns
• Post-surgical or post-operative wounds
• stitches
• blisters
• skin tears
• animal, insect or human bites
• radiotherapy skin reactions.

This article will focus specifically on the management of three common types of wounds seen in pharmacy: abrasions, cuts and burns. The dressing types recommended are consistent with the terminology used in the Australian Pharmaceutical Formulary and Handbook (APF) section ‘Wound management’. Pharmacists can refer to the APF for examples of products and their manufacturers.

Upon presentation of a wound, pharmacists are advised to reflect on their current knowledge, skills and training to adequately assess and/or treat a wound. If outside their individual or professional scope, referral for further assessment and treatment is indicated.⁹

Abrasions

Abrasions are superficial injuries where the epidermis is damaged or disrupted by friction such as scraping, impact or pressure.^10,11 Grazed abrasions or ‘road rash’ result from friction against a broad, rough surface, such as when a person falls off a skateboard or bike and their body is scraped across the road surface.¹¹ Abrasions commonly occur over bony prominences of the knees, elbows and face.¹⁰

Assessment

Pharmacists should take a thorough history of the accident details to determine the time of the accident; the extent, depth and degree of contamination; and the implications of the injury. In addition, pharmacists should assess for any bruises, haematomas (a localised collection of blood in the tissues of the body outside of the blood vessels), and possible fractures.^12,13

Indications for referral

• Excessive bleeding even with firm pressure applied for 15 minutes.
• Wound is contaminated with dirt, soil, gravel and debris which cannot be removed.
• Patient with diabetes.
• Unsure of the patient’s tetanus vaccination status.
• Signs of infection.
• No significant improvement within 7–14 days.

Management^10,12

1. Wear disposable gloves or wash hands well when gloves are not available.
2. Cleanse the area with sterile normal saline (0.9% sodium chloride) or tap water alone. If potentially contaminated with particulate matter, gently remove using gauze swabs soaked with normal saline. Embedded debris should not be scrubbed away, as this can further traumatise the site.
3. If the wound is grossly contaminated or at high risk of infection, an antiseptic such as povidone-iodine solution may be used. Povidone-iodine solution should be washed off within 5 minutes of application.
4. Pat the surrounding skin dry with a clean pad or towel.
5. Choose a dressing according to the nature and location of the wound. For example, a simple abrasion may be covered with an island film dressing, which has a low-adherent, low-absorbent dressing pad. For moderately exuding wounds, a silicone-coated foam dressing may be appropriate.
6. Change the dressing according to the manufacturer’s instructions, as some may be left in place for several days to a week depending on wound assessment and levels of exudate.

Cuts and lacerations

A laceration is a wound caused by blunt force mechanical trauma, and usually the wound presents with irregular jagged edges.^11,14 Lacerations often occur as a result of a fall and are often situated on the scalp or the bony prominences of the face.¹⁰

A cut or incised wound is also caused by mechanical trauma but is caused by a sharp or cutting force or object, such as a knife or glass cutting the skin.^11,14 Cuts tend to occur on the fingers, hands and feet.¹⁰

Assessment

Pharmacists should observe the wound and collect a focused history to include the time and mechanism of injury that led to the cut/laceration. It is important to determine the location of the wound, its shape and size, the involvement of deeper structures, and the degree of external contamination by dirt or foreign material.¹⁰

A comprehensive medical history should be taken to pre-empt any possible complications such as issues with haemostasis for patients on anticoagulants or platelet inhibitors.¹⁵

Indications for referral^11,15,16

• Suspected injury to underlying deeper structures including nerves, tendons, named blood vessels, viscera, bones and joints.
• Significant contamination, e.g. by dirt, soil or foreign bodies.
• Significant tissue loss.
• Inability to close wound edges by primary intention, i.e. the wound ‘gapes’.
• Wound does not stop bleeding after 15 minutes when pressure is applied.
• Wound is more than a few millimetres deep.
• Wound is near the eyes or eyelids.
• Animal or human bite.
• Patient has diabetes.
• Unsure of the patient’s tetanus vaccination status.
• Areas of skin loss on fingertips more than 1 centimetre.²

Management^{9–11,15–17}

1. Wear disposable gloves or wash hands well when gloves are not available.
2. Apply firm direct pressure on the wound with a compressive bandage or clean cloth to stem the blood flow. If possible and applicable, raise the injured area above the level of the patient’s heart.
3. Cleanse the area with sterile normal saline (0.9% sodium chloride) or tap water alone. If potentially contaminated with particulate matter, gently remove using gauze swabs soaked with normal saline.
4. If the wound is grossly contaminated or at high risk of infection, an antiseptic such as povidone-iodine solution may be used. Povidone-iodine solution should be washed off within 5 minutes of application.
5. Pat the surrounding skin dry with a clean pad or towel.
6. Small, simple, superficial cuts/lacerations with opposed edges which are not separated do not require closure. Cuts/lacerations that have slightly separated skin edges on non-hairy areas of the body can be closed with wound closure strips.
7. Closure strips should be applied at right angles to the wound, 3–5 mm apart, starting from the middle of the wound. For areas on flexures, elastic wound closure strips are available.
8. For protection, a low-adherent dressing pad with a secondary dressing (e.g. film) to keep in place, or use of an island dressing, is often appropriate to cover the wound. Change the dressing according to the manufacturer’s instructions. Keep the area dry for 72 hours. 

Minor burns 

An epidermal burn is one where the epidermis is damaged but intact, appears pink/red, and is possibly painful, e.g. sunburn. These types of burns usually heal within 3–7 days.¹⁷

A superficial dermal burn is one where the epidermis and top part of the dermis is painful, pale pink/red, raw, moist, often blistered with peeling skin, and the wound base blanches to pressure, e.g. water scalds.^18,19 Significant exudate is often produced in the first 72 hours, but these burns usually heal within 7–12 days.^17,19 

The Pharmacist Advice Card for Burn Injury is available on the Australian and New Zealand Burn Association (ANZBA) website, which pharmacists can refer to as a guideline when a patient presents with an acute burn²⁰ (https://anzba.org.au/care/pharmacy-advice/). 

Assessment 

Pharmacists should ascertain the cause, timing and exact mechanism of the injury to determine the severity of the burn.¹⁹ 

Assess the wound based on the size, percentage of body surface area affected, moisture, burn depth, anatomical site of the injury, pain levels, and the presence of co-existing conditions. In elderly patients, identify if there are any safety concerns that may need to be addressed, including whether the burn injury is a symptom of broader frailty.¹⁹ 

Patients presenting to the pharmacy may have already performed first aid on the burn. It is important to determine what was done, when it was performed, and if it was within 3 hours and maintained. 

Indications for referral ^9,17,19,21 

Burns can be life-threatening, and urgent referral to a hospital or emergency department may be required. 

Refer to the ANZBA Pharmacist Advice Card for Burn Injury for further information on where to refer based on assessment of burns. 

Patients should be referred in the following circumstances: 

• burns >3 cm*
• burns of special areas, including the face, ears, eyes, neck, airway, hands, feet, genitalia, perineum, major joints and circumferential limb, or chest burns, even if <10% total body surface area (TBSA)
• burns with inhalation injury
• electrical burns
• chemical burns
• deep burns
• pre-existing illness
• burns associated with major trauma
• extremes of age – young children (<12 months) and the elderly
• pregnancy
• non-accidental injury (including suspected)
• signs of infection
• burn that is slow to heal (e.g. poor progression at 5–7 days)
• burn that is unhealed (>14 days)
• uncertainty about severity
• moderate-severe pain
• presence of blisters

* Note: burns >5% TBSA (for children or full thickness in any age), or burns >10% TBSA in adults, should be referred immediately to a burns unit. TBSA does not include epidermal burn (e.g. sunburn).²¹ 

Management
Management of epidermal burns ^9,19,22: 

1. Cool the burn with running water (ideally 15 °C) for 20 minutes. This is effective for up to 3 hours after the burn occurs. Do not apply ice. If access to running water is not available, consider: spraying with cool water

• spraying with cool water
• sponging with wet cloth/towels
• immersion in water
• using a water gel product in adults only, e.g. a hydrogel. 

2. Ensure adequate hydration. 
3. Once the skin is cooled, apply a soothing aqueous cream (e.g. moisturiser). A hydrogel could be used to soothe the area. 
4. Provide short-term (<72 hours) oral analgesia if necessary. 
5. A dressing is usually not needed. 

Management of superficial dermal burns ^9,18–20,23: 

1. Remove any jewellery and clothing in contact with the burn source. 
2. Cool the burn with running water (ideally 15 °C) for 20 minutes (as described above for management of epidermal burns). 
3. Remove any wet clothes/dressings after initial cooling. Observe and prevent hypothermia by keeping the patient warm. 
4. Ensure adequate hydration. 
5. If the patient requires transfer to hospital, the burn may be loosely covered with non-adherent inert dressing or cling wrap prior to transfer. If the burn is severe, the burns unit may be contacted for advice on actions required before and during transit to hospital. 
6. Provide short-term (<72 hours) oral analgesia if necessary. 
7. Clean the wound bed if necessary (e.g. with normal saline). 
8. A dressing should be selected according to the nature and location of the wound as well as patient circumstances:

• Burn wounds are dynamic, it may be necessary to consider a different dressing with lesser absorbency capacity at each dressing change, as the wound improves and the amount of exudate is lessened.
  • For wounds with moderate-high exudate, an absorbent foam dressing or alginate dressing may be considered.
  • For wounds with low exudate, a low-adherent island film dressing, a thin hydrocolloid, or light silicone coated foam dressing may be considered.
  • For dry wounds that need moisture, a sheet hydrogel or amorphous hydrogel may be selected which requires a secondary dressing to hold the gel in place.
• If the burn wound is at risk of infection, silver antimicrobial dressings (which come in many forms) may be considered.
• If adhesives cannot be applied to the skin, secure the dressing with crepe or support bandages, but ensure it is non-constrictive.

9. If appropriate, elevate the affected area to minimise oedema. 

Knowledge to practice 

There is scope for pharmacists to deliver wound care services in the pharmacy with varying degrees of complexity; it could involve providing education to patients on wound prevention, identifying and addressing intrinsic and extrinsic factors that may delay wound healing, supplying therapeutic products, counselling on how to select and use a particular dressing appropriately to promote moist wound healing, or identifying indications for referral to another healthcare professional if necessary. Cost-effectiveness of different dressings and schedules may also be pertinent to consider for patients, in particular circumstances. 

Some pharmacies offer more advanced wound care services, which could involve using the pharmacy’s consultation room to assess, cleanse and dress a patient’s wound in the pharmacy following appropriate training in wound management. 

When administering wound care and providing advice, pharmacists should also consider if the injury might be an accident or possibly caused by suspected abuse, non-suicidal self-injury or domestic violence.¹⁵ For information on how to appropriately respond, please refer to resources, training and advice from organisations such as:

• 1800 RESPECT (www.1800respect.org.au/)
• DV-alert (www.dvalert.org.au/)
• Mental Health First Aid Australia (https://mhfa.com.au/)
• Lifeline (www.lifeline.org.au/) 

When delivering wound care services, ultimately the goal is to achieve an improvement in patient outcomes and promote successful healing of acute wounds, while offering accurate and professional advice, support, referral pathways and service delivery where appropriate. 

Conclusion 

With greater knowledge of acute wounds, pharmacists can confidently implement wound management principles to identify, assess, manage and know when to refer for specific wounds. Pharmacists should use their professional judgement when deciding whether to counsel the patient on how to self-treat the wound and supply appropriate therapeutic products, refer the patient to a medical practitioner or hospital, or assist them in the treatment of the wound in the pharmacy’s wound clinic and document the interaction appropriately.

Key points 

• When an acute wound is presented in pharmacy, pharmacists should first identify the wound, perform an assessment of the degree of severity, refer if necessary, and use their clinical judgement to decide on the level of involvement with the management of the wound.
• It is important for pharmacists to be confident and knowledgeable about the most common types of acute wounds seen in pharmacy, particularly abrasions, cuts/lacerations and burns.
• Most acute wounds that present to the pharmacy are minor, however pharmacists should be aware of indications for referral to a medical practitioner or hospital.
• There is scope for pharmacists to further their wound care training and possibly implement wound care services in their pharmacy to benefit their greater community.

If you do get an enrolment error, please click here

References

1. Australian Government Department of Veterans’ Affairs. Wound care module. 2016. At: www.dva.gov.au/sites/default/files/files/providers/woundcare/woundcaremodule.pdf.
2. Tottoli EM, Dorati R, Genta I, et al. Skin wound healing process and new emerging technologies for skin wound care and regeneration. Pharmaceutics 2020;12(8):735.
3. Lazarus GS, Cooper DM, Knighton DR, et al. Definitions and guidelines for assessment of wounds and evaluation of healing. Arch Dermatol 1994;2(3):489-93.
4. Spear M. Acute or chronic? Whatʼs the difference? Plast Surg Nurs 2013;33(2):98-100.
5. Firipis M. Wound wisdom. 2015. At: www.postscript.com.au
6. University of Queensland Therapeutics Research Unit. Wound care benchmarking in community pharmacy –piloting a method of QA indicator development. 2003.
7. Haggan M. Heal them and they will come. AJP 2006;87:48-9.
8. Huxhagen K. CPD: Supporting your practice: wound management and dressings. Australian Pharmacist 2018;37(8):38-44.
9. Sansom LN. Australian pharmaceutical formulary and handbook. 25th edn. Canberra: Pharmaceutical Society of Australia; 2021.
10. Young SJ, Barnett PLJ, Oakley EA. 10. Bruising, abrasions and lacerations: minor injuries in children I. Med J Aust 2005;182(11):588-92.
11. Healthdirect. Wounds, cuts and grazes. 2021. At: www.healthdirect.gov.au/wounds-cuts-and-grazes
12. Abrasions [revised Jan 2019]. In: eTG complete. Melbourne: Therapeutic Guidelines; 2019.
13. Shiel W. How do you tell if a bruise is a hematoma? 2022. At: www.medicinenet.com/hematoma_vs_bruise/article.htm
14. Zulkowski K. Wound terms and definitions. WCET 2015;35(1):22-7.
15. Turner RC, Tran V. Acute lacerations. Aust J Gen Pract 2019;48(9):585-8.
16. The Royal Children’s Hospital Melbourne. Clinical practice guidelines: lacerations. 2022. At: www.rch.org.au/clinicalguide/guideline_index/Lacerations/
17. Australian and New Zealand Burn Association. ANZBA referral criteria. 2019. At: www.anzba.org.au/
18. Minor burns [revised Jan 2019]. In: eTG complete. Melbourne: Therapeutic Guidelines; 2019.
19. Victorian Adult Burns Service. Minor Burns. At: www.vicburns.org.au/minor-burns/
20. Australian and New Zealand Burn Association. ANZBA guidelines for pharmacist advice card for burn injury. 2019. At: www.anzba.org.au/care/pharmacy-advice/
21. The Royal Children’s Hospital Melbourne. Clinical practice guidelines: burns-acute management. 2020. At: www.rch.org.au/clinicalguide/guideline_index/Burns/
22. QLD metro north hospital and health service. Burns patient information. 2017. At: https://metronorth.health.qld.gov.au/rbwh/wp-content/uploads/sites/2/2017/06/burns-patient-factsheet.pdf
23. World Union of Wound Healing Societies (WUWHS) Consensus Document. Wound exudate: effective assessment and management. Wounds International; 2019.

Our author

Daisy Cheung (she/her) BPharm, MPS is a community pharmacist, university teaching associate, and sessional lecturer at the University of Sydney School of Pharmacy. Her PhD candidature research involves the role of community pharmacy in wound care.

Our reviewer

Lusi Sheehan (she/her) BPharm, AACPA, GradCertWoundCare,DipMgt, AdvPP(II), MPS