David M. Cline
After repair, proper care is focused on optimized healing and prevention of complications. Considerations include use of dressing, positioning, prophylactic antibiotics, and tetanus prophylaxis.
Appropriate follow up and patient education regarding cosmetic results are important.
USE OF DRESSINGS
Wound dressings provide a moist environment that promotes epithelialization and speeds healing.
Semipermeable films such as Op Site® are available in addition to conventional gauze dressings. The disadvantages of these materials are their inability to absorb large amounts of fluid.
Alternatively, topical antibiotics may be used to provide a warm, moist environment.
Topical antibiotics may reduce the rate of wound infection and also may prevent scab formation.
Wounds closed with tissue adhesives should not be treated with topical antibiotic ointment because it will loosen the adhesive.
PATIENT POSITIONING AFTER WOUND REPAIR
The injured site should be elevated, if possible, to reduce edema around the wound and speed healing.
Splints are useful for extremity injuries because they decrease motion and edema and increase attention paid to the body part.
Pressure dressings minimize the accumulation of fluid and are most useful for ear and scalp lacerations. (see Chapter 13).
PROPHYLACTIC ANTIBIOTICS
Prophylactic oral antibiotics are only indicated in specific clinical circumstances.
When deciding whether or not to prescribe antibiotics, consider the mechanism of injury (ie, crush injury), degree of bacterial or soil contamination, and host predisposition to infection.
Prophylactic antibiotics are recommended for human bites, dog or cat bites on the extremities (see Chapter 17), intraoral lacerations (see Chapter 13), open fractures, and wounds with exposed joints or tendons (see Chapters 14 and 15).
Patients with wounds in areas with lymphedema will likely benefit from prophylactic antibiotics as well.
A 3- to 5-day course is adequate for non-bite injuries and a 5- to 7-day course is adequate for bite wounds.
TETANUS PROPHYLAXIS
The need for tetanus prophylaxis should be considered for every wounded patient.
Inquire about the mechanism of injury, age of the wound, and the patient’s tetanus immunization status.
The only contraindication to tetanus toxoid is a history of neurologic or severe systemic reaction after a previous dose.
See Table 18-1 for a summary of recommendations for tetanus prophylaxis.
WOUND CLEANSING
Sutured or stapled wounds may be cleansed as early as 8 hours after closure without increasing risk of wound infection.
Wounds should be gently cleansed with soap and water and examined for signs of infection daily.
Application of topical antibiotics for the first 3 to 5 days decreases scab formation and prevents edge separation.
Patients with wounds closed with tissue adhesives may shower, but should not immerse the wound, as this will loosen the adhesive bond and cause earlier sloughing of the adhesive.
WOUND DRAINS
Drains are placed in wounds for removal of interstitial fluid or blood, to keep an open tract for drainage of pus, or to prevent an abscess from forming by allowing drainage from a contaminated area.
Closed drainage systems have largely replaced open wound drains, especially after surgery, because closed systems prevent bacteria access into the wound.
Ribbon gauze packing in an abscess cavity after I&D is the most common drain used in the ED. Packing should be changed at each follow-up until the wound stops producing exudate.
PAIN CONTROL
Inform patients about the expected degree of pain and measures that might reduce pain. Splints help reduce pain and swelling in extremity lacerations.
Analgesics may be needed although narcotic analgesia is rarely necessary after the first 48 hours.
HEALTH CARE PROVIDER FOLLOW-UP
Provide specific instructions for wound examination or suture removal.
Patients with high risk wounds or conditions, or those unable to identify signs of infection should be instructed to return for re-examination, usually in 48 hours.
Facial sutures should be removed in 3 to 5 days.
Most other sutures can be removed in 7 to 10 days, except for sutures in the hands or over joints, which should remain for 10 to 14 days.
When removing sutures or adhesive tapes, take care to avoid tension perpendicular to the wound, which could cause dehiscence.
Tissue adhesives will slough off within 5 to 10 days of application.
TABLE 18-1 Recommendations for Tetanus Prophylixis
PATIENT EDUCATION ABOUT LONG-TERM COSMETIC OUTCOME
Inform patients that all traumatic lacerations result in some scarring and that the short-term cosmetic appearance is not highly predictive of the ultimate cosmetic outcome.
Instruct patients to avoid sun exposure while their wounds are healing because it can cause permanent hyperpigmentation.
Patients should wear sunblock for at least 6 to 12 months after injury.
For further reading in Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed., see Chapter 51. Postrepair Wound Care, by Adam J. Singer and Judd E. Hollander.