Common First Aid question answered here! READ FIRST
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Normally wound healing takes place over 3 stages which help your body to repair. These stages can be disrupted however by infection/ picking/ pulling at the wound this can cause problems either by stopping the wound from keeping healing or going back to a previous stage.
This article is looking at the stages a wound normally goes under when healing and so what you should expect to see so you know if what you’re seeing is normal or not.
Stage 1- Inflammation
· Starts straight after you cut and lasts for 3-5 days; the worse the cut generally the longer it lasts especially if the area is one where the skin moves a lot of is under a lot of tension.
· Chemicals in your body realise some damage has been done and if blood vessels are damaged it starts bleeding which helps clean the wound. Your body will act to stop any bleeding by narrowing damaged vessels & clot blood; these early clots can easily become infected so be aware of that and wound care should be started ASAP after the wound has been made.
· 5-10minutes later blood supply around the area increases (and so it is normal for it to be reddened, allowing more nutrients to get to the damage) and the vessels become ‘leaky’. Specific cells are then attracted to the area to clear up as much debris as possible. The vessels becoming leaky means it is normal for the area to become swollen. The added fluid in the area also dilutes and debris in the wound to reduce its affect.. The fluid seen here can leak from wounds and is clear, sticky, thin and has no smell to it; it helps healing by keeping the area moist and isn’t a sign of infection. It can also form the scab
· After 30-60minutes White Blood Cells get to the area staying there for the next few days (longer if it becomes infected). These aim to remove more debris and destroy as much bacteria as they can.
· The White Blood Cells also signal out commands for the blood vessels to be repaired and new ones created which can increase any reddening
· Through this stage pain is usual and the inflammation increases it through several means
Stage 2- Repairing
· Starts as soon as the inflammation reduces until the wound closes and heals
· The body starts to use the scaffold across the wound to repair it as some cells start to move into it and at the same time blood vessels are made which loop up into it so the cells have what they need to repair the wound.
· In Deep Wounds ONLY; The blood vessels and some white blood cells as well as cells surrounding the wound start to lie below the scab (or at the bottom of the wound if a scab is not present) to create a pink tissue with red spots. This looks quite moist and is called Granulation tissue; a healthy sign of healing but is only seen in cuts that go all the way through the skin; it’s not needed in others. If healthy this granulation tissue (or, if present the scab covering it) protects the wound from bacteria entering and so it should be left alone. If it doesn’t develop over some areas the wound needs to be checked out if it is deep.
Granulation tissue can often be confused with infection as they both produce a discharge. Infectious discharge tends to be yellow- green in colour and smelly whereas granulation tissue, especially when left with a dressing on, can be seen to have a white, 'gooey' discharge in the gaping wound.
This, though commonly mistaken for pus is NORMAL. When your body is healing there are cells which end up no longer being needed as well as tissue fluid which exits your body through the wound to moisten the area and aid healing. These cells along with the fluid and the fact that a lot of the cells in the area are white blood cells during normal healing means the discharge is white and it is a sign things are going well and healing as this also contains chemicals in it which will stimulate healing further.
One easy way I think would be helpful to remember is if the discharge is green-yellow/ smells or the wound is becoming more reddened/ painful/ swollen/ warm, then these are signs that there is an infection brewing so if you're unsure and you have these signs then it is a good idea to see your doctor to see if it is infected.
· Over time this scaffold will reduce in size, bringing the edges of the wound closer (if it’s gaping or the it is a graze where the top areas will be pulled closer) and from the 6th Day of healing Collagen (which is a protein) starts to form strands which lie across the wound and become stronger before they pull at the edges of the wound to bring them closer every day. This will also happen if you damage a muscle, making it shorter which causes a lot of problems later on so you should seek help if you ever feel you may have injured a muscle.
· Over the top of this, cells then start to move into the wound towards the centre leading to new skin being formed at the edges (if a wound is closed with stitches you may see that the surface looks closed over due to this after 2-3days. It is only the surface of the wound, below this healing hasn’t really occurred so stitches must stay in longer).
· The size of the wound determines closure. If the edges touch it can be within a couple of days. Gaping wounds on the other hand can take several weeks.
Stage 3- Remodelling
· The cut has now healed but the tissue that replaces it isn’t normal skin, it is scar tissue which isn’t as strong and unlike skin doesn’t stretch. To cope, body then continuously alters the scar attempting to make it stronger
· If it isn’t strong enough more layers are built in which makes the scar raised
· Overtime as the collagen is organised the best way it puts the edges of the scar together making the scar smaller and reducing the number of layers when then they are not needed so it flattens
· Overtime the cells don’t need as much blood and so the blood supply reduces back to that of normal skin and with this the scar fades.
· This always occurs normally with scars (unless a defect means it becomes a Keloid Scar) but massaging the scar and using Cocoa Butter/ Vit E cream/ Bio-Oil/ Scar Reducing Pads can speed up the process however it still takes weeks.
What are Steri-strips?
They are the most common trade name for closure strips and there are similar products on the market known as Butterfly stitches (/bandages). Throughout the rest of this article we will refer to closure strips of Steri-Strips for ease though there are many other products are as good as Steri-Strips available on the market.
Steri- strips are thin pieces of specialised sterile tape, which can be used to hold the edges of a wound together in order to promote better healing, reduce the chances of infection and often result in reduced scarring.
Steri-strips do not hold wounds together as strongly as stitches would do, however, they work well for smaller cuts (recommended for wounds less than 4mm deep/ 5mm wide.) Their application is simple and almost painless and if used correctly they can leave less of a scar than stitches may do.
Never close a wound if it is over 24hrs old, shows signs of infection, or hasn't been thoroughly cleaned. See the wound care guide the information on that.
Any cut which is;
· wider than 5mm
· has bled for greater than 10mins with pressure on it
· is down to fat
· causes problems with movement in the area
· you have areas of numbness/ electric shock feelings which you think may be caused by the wound
· is on your face/ genitals/ near a joint or gaping at all and on your lower leg
needs to be assessed by a medical professional & not be steri-stripped by yourself.
The use of Steri-strips is NOT a replacement for good medical advice.
Preparing a cut for using closure
Only apply steri-strips once the wound and surrounding area has been thoroughly cleaned and it has stopped bleeding fully; 2hrs after bleeding has ceased is a good point as the clots are more stable. If it bleeds as you are applying them, stop and once apply pressure to the wound
· If anything is embedded in the cut you NEED to get it checked out by a medical professional
· Clean your hands and if possible apply latex/ medical gloves when dealing with the wound to reduce the chance of infection
· Clean the cut and surrounding area; at least 5cm around the whole cut. Be gentle when you do this ensuring that no extra damage is done. You may use sterile swabs/ gauze to help you clean the wound and surrounding area. Clean the inside of the wound first and then move onto the surrounding area of skin; NEVER use anything that you've used to clean the surrounding skin back onto the cut- you will be transferring bacteria into it. Cleaning the wound may take a few minutes. It is best to use a saline solution, previously boiled lukewarm water, or a shop bought wound wash for cleaning wounds.
o NEVER use products that contain Hydrogen Peroxide or Alcohol. They damage the healthy cells, reducing healing. Saltwater is no longer advised either as it slows healing.
· If you have some Tincture of Benzoine you may apply it finely and carefully 25-30mm away from the edge of the wound in a line parallel to its entire length and allow it to dry; this helps the strips to stick.
Directions for application
· Work out how many you are likely to need by looking at the size of the cut; They should be placed the whole way down the length of the cut, leaving a gap between each one of 2 to 3 mm to allow any discharge to drain
· Cut each Steri-strip to the correct length with clean scissors so that it is big enough for 30mm to be applied to the skin at either edge of the wound
· Strips should be placed across a cut, not lengthways ie. the end of each strip should be applied 30mm away from the cut and the Steri-strip running perpendicular to it holding the wound closed.
· Start applying them at the centre of the wound
· Apply one half of the strip to the skin at one side of the wound and press it firmly into place.
· Pull the skin at either edge of the wound together and press the other half of the strip down firmly so that the centre of the cut is held closed.
· Complete the closure of the wound using additional strips, placed 2-3 mm from the next. You may need to reapply the first (or any other) strip(s) as it may have come loose when applying the rest.
· Once the cut has been closed you can use 2 other steri-strips; 1 for either side of the wound. These should be placed covering the ends of the strips and parallel to the wound, holding them down to your skin for added security to form a '#' sort of shape
If the wound does not stop bleeding once the strips have been applied or the edges do not come together they may not suitable for your wound so further medical attention is advisable.
Care of steri-strips
The wound should be kept clean, dry and covered with a low-adherance dressing pad (e.g.Melolin)held in place with either a bandage or medical tape (or using an adhesive dressing). Ensure that the strips are totally covered by the gauze pad in the centre of the dressing.
If you need to take a shower, use a plastic bag held in place with water-proof tape to protect the area. Some really thin film based water-proof dressings (such as OpSite) may help keep the water out but be careful as some may leak. Generally the thinner they are the less likely it is for them to leak. As soon as you get out of the water check the dressing for any leaks and if it has leaked, remove the dressing, dry the area and apply more Steri-Strips if necessary and a new dressing .
If you go in the bath, try and keep the affected area out of the water.
Loose edges of the strips can be trimmed to prevent them from catching on things.
Monitor the wound for signs of infection. These include but aren’t limited to,
· Thick, yellow/green, smelly, pussy discharge
· Redness, swelling, pain around the area
· Reduced healing
· Increase in size of the wound
· Red lines spreading from the cut into surrounding skin (Tracking)
· Fever or chills If you wound begins to show signs of infection, you should contact your doctor for advice as you may need anti-biotic treatment. Removing the strips if you feel it is infected is a good idea.
Removal of Steri-Strips
Steri-Strips should be left in place for 5-7 days for cuts a couple of mm wide or up to 10 days for ones up to 5mm wide or on areas of skin that are close to joints or on your lower arm/leg. Anything wider than this needs to be assessed by a doctor/nurse for stitches.
When removing them, be careful not to reopen the wound. It might be useful to soak the strips in some water as you remove them as this will loosen the adhesive holding them in place.
To remove them gently pull one end of the strip up at around a 45o angle to your skin and peal it away.
If the wound is not fully healed then continue applying dressings to it. If it reopens again soon after remove the Steri-Strips, you can Steri-Strip the wound closed again.
Making Butterfly Bandages This is a practice that is the only advised if the wound needs closing and you haven't got any Steri-Strips available. Using shop bought closure strips is a much better idea than making your own, these will be sterile and also designed for this purpose so won't interfere with wound healing and won’t re-open wounds when removed.
· Cut off lengths of Micropore Tape around 6 cm in length using clean scissors
· At a third of its length, cut slits in the Micropore Tape, towards the centre on either side of the tape leaving the central third of the tape intact. Now do this at the other side of the length of tape.
· This will leave to thick sections at the edge and then the centre which will have a flap on either side.
· Fold the flaps into the central area on either side of the central portion of the Tape so it's not sticky
· Apply in the same way as Steri-Strips, but have the non-sticky area overlying the wound
· If possible, ensure you replace them with Steri-Strips if you have a chance to buy them, being careful and only taking one butterfly strip off and replacing it with one Steri-strip at a time to prevent re-opening.
Pictures of the making and application of 'butterfly stitches' which may make the process clearer for some people;