Basics of Wound Management

The approach to the management of a particular wound and the decision to close a wound immediately or after a period of observation are based primarily on factors that affect the risk for infection.

History

• Wound age
• Additional factors: medications, allergies, tetanus immunization status, potential exposure to rabies, potential for foreign bodies embedded in the wound, previous injuries and deformities, associated injuries, and other factors such as age, health status, availability for follow-up, and patient understanding of wound care or compliance

Delayed Primary or Secondary Closure

• There is no urgency in closing a wound. Deciding whether to use delayed primary or secondary closure is determined by the risk for infection. If the status of the wound is uncertain, delayed primary closure is another available option.

• There are no contraindications to wound management.

• Sterile gloves
• Sterile surgical towels and/or fenestrated drape
• Face mask
• Sterile gauze
• 2 fine single- or double-pronged skin hooks
• Scalpel with a No. 15 blade
• Tissue scissors
• Hemostats
• Small tissue forceps
• 19-gauge plastic catheter or needle and 35-mL syringe for irrigation
• Splash shield for irrigation syringe (ZeroWet Splashield, Zerowet Inc., Palos Verdes Peninsula, Calif)
• Sterile saline for wound irrigation
• For wounds in hair-bearing regions: petrolatum jelly or water-soluble ointment and/or small scissors to remove hair
• Good lighting source
• Tourniquet (may be needed if bleeding is not controlled)
• Non-adherent dressing material
• Absorbent dressing material
• Outer wrapping for dressing (Kerlix, Kendall Healthcare Products, Mansfield, Mass; Kling stretch gauze, Johnson & Johnson, New Brunswick, NJ)
• Topical antibiotic preparation (optional)
• Supplies for local or regional anesthesia

Wound Healing

• Once a wound is closed, the initial phase of wound healing during days 0-5 is the inflammatory phase.
• Within 48 hours, the epithelium regenerates and closes off the external surface of the wound to protect it from contamination.
• The fibroblast phase begins around 48 hours after injury.
• Collagen production reaches its peak about 7 days later and has the most mass at 3 weeks after injury.

Dressings

• Wipe away dried blood and cover the wound with a nonadherent dressing constructed in three layers: a nonadherent contact layer, an absorbent layer, and an outer wrap.

Splinting and Elevation

• Splints are almost always required for lacerations that overlie joints and are frequently necessary for protection of wounds involving fingers, hands, wrists, the volar aspects of forearms, the extensor surfaces of elbows, the posterior aspects of legs, the plantar surfaces of feet, and the extremities when skin grafts have been applied.
• Elevation of injured extremities is important in all but trivial injuries.

Ointments

• The safety and efficacy of topical antibiotic preparations used on wound surfaces are unproven, but ointments may reduce adherence of the dressing to the wound.

Systemic Antibiotics

• Prophylactic antibiotics do not reduce the incidence of infection.
• Antibiotics should be considered for extremity bite wounds; puncture-type bite wounds; intraoral lacerations; orocutaneous lip wounds; wounds that cannot be cleaned or debrided satisfactorily; highly contaminated wounds; wounds involving tendons, bones, or joints; wounds requiring extensive debridement in the operating room; wounds in lymphedematous tissue; distal extremity wounds when treatment is delayed for 12 to 24 hours; patients with orthopedic prostheses; and patients at risk for developing infective endocarditis.

Immunoprophylaxis

• If appropriate, administer tetanus prophylaxis in the ED.
• Patients who have not completed a full primary series of injections may require both tetanus toxoid and passive immunization with tetanus immune globulin.

Patient Instructions

• Inform patients that there will be a scar and advise them of the stages of healing and appearance of the scar.
• Dysesthesia and anesthesia may occur and usually resolve in 6 months to 1 year.
• Instruct the patient to protect the wound by keeping the dressing clean and dry for 24 to 48 hours.
• After 48 hours, have the patient with uncomplicated wounds remove the dressing and check for evidence of infection.
• Reevaluate patients with complicated or infection-prone wounds within 2 days.
• Patients may bathe with sutures in place, but instruct them to not immerse the wound for a prolonged time.
• Have patients leave the splint undisturbed until the sutures are removed.
• Instruct patients with intraoral lacerations to use warm salt water mouth rinses at least three times a day.

Reexamination

• Discharge patients with appropriate instructions for home care and instructions to return for suture removal. Evaluate wounds being considered for delayed primary closure in 4 to 5 days.
• Reexamine high-risk wounds, such as bite wounds and other infection-prone wounds, in 2 to 3 days for signs of infection.

Suture Removal

• Remove sutures on the face on the fifth day following the injury, or remove alternate sutures on the third day and the remainder on the fifth day.
• On the extremities and the anterior aspect of the trunk, leave sutures in place for approximately 7 days to prevent wound disruption.
• Leave sutures on the scalp, back, feet, and hands and over the joints in place for 10 to 14 days, even though permanent stitch marks may result.
• Some clinicians recommend the removal of sutures in eyelid lacerations as early as 72 hours to avoid epithelialization along the suture tract, with subsequent cyst formation.

• Wound infection
• Failure to heal
• Dehiscence of the wound
• Scarring