I. OVERVIEW AND GOALS OF WOUND MANAGEMENT
Emergency wound care is a foundational skill in Emergency Medicine. The primary goals of wound management are:
- Hemostasis – Control active bleeding.
- Infection Prevention – Through effective cleansing, debridement, and, when appropriate, antibiotics.
- Cosmesis – Minimize scarring by appropriate closure technique and tension management.
- Function Preservation – Avoid tendon, nerve, joint involvement sequelae.
- Patient Satisfaction – Through education, clear expectations, and proper discharge instructions.
II. WOUND ASSESSMENT AND DECISION MAKING
A. Initial Evaluation
- History: Mechanism, timing, contamination source (soil, saliva, feces), foreign body potential, tetanus status.
- Physical Exam: Inspect wound length, depth, location Assess for involvement of tendon, joint capsule, neurovascular structures Check for active bleeding, pulsatile flow
B. Imaging
- Plain Radiographs – Detect radiopaque foreign bodies, fractures
- Ultrasound – For non-radiopaque foreign bodies (glass, wood)
- CT – For deep or complex wounds, especially near critical structures
C. Wound Classification
D. Closure Decision
- Primary closure: Low-risk wounds within 12 hours (face: up to 24 hrs)
- Delayed primary closure: High-risk, contaminated wounds after 3-5 days
- Secondary intention: Dirty wounds, high risk of infection, or minimal tissue loss
III. WOUND PREPARATION
A. Anesthesia
- Lidocaine 1% (with or without epinephrine)
- Buffering: Add 1 mL bicarb per 10 mL lidocaine
- Regional nerve blocks: For digits, face, scalp
B. Hemostasis
- Direct pressure
- Lidocaine with epi
- Tourniquet (digital or limb)
- Cautery (for superficial bleeding)
C. Cleansing and Irrigation
- Irrigate ALL wounds before closure (unless very superficial)
- Normal saline or tap water (equally effective)
- High-pressure irrigation: 30-60 mL syringe with 18G catheter (~7-10 psi)
- Volume: ~50–100 mL per cm of wound length
Skin Antisepsis
Agents and Indications:
- Chlorhexidine-alcohol (CHG-alcohol):
- Broad-spectrum efficacy against bacteria, moderate effectiveness against fungi and viruses.
- Superior in reducing surgical site infections (SSIs).
- Application: Rapid drying (30 sec), ideal for intact skin.
- Caution: Avoid direct contact with wounds, eyes, and mucous membranes (risk of corneal damage).
- Povidone-iodine (Betadine):
- Effective against gram-positive, gram-negative bacteria, fungi, and viruses.
- Preferred for mucous membranes or open wounds due to lower tissue toxicity compared to CHG.
- Application: Allow to dry for 2-3 minutes; avoid contact with the wound bed to reduce toxicity.
- Dermacyn (Hypochlorous acid):
- Not recommended for initial skin prep; used only post-debridement irrigation due to rapid degradation upon organic matter contact.
Practical Application Steps:
- Select appropriate antiseptic based on patient and procedural factors.
- Apply antiseptic with sterile gauze or applicator using friction.
- Allow adequate drying time:
- CHG-alcohol: ~30 sec
- Povidone-iodine: 2-3 mins
Hair Management:
- Hair removal is generally unnecessary for reducing infection risk.
- When required, use electric clippers or scissors.
- Never use razors: Razors significantly increase infection risk (3-9 times higher) due to follicular damage.
- Exception: Eyebrows should not be shaved to preserve anatomical landmarks and ensure proper regrowth.
Wound Preparation and Management
Debridement:
- Crucial for wound healing and infection control.
- Remove all devitalized tissue and foreign material.
- Balance aggressive debridement with preservation of viable tissue, particularly on the face and hands.
- Consider delayed primary closure for extensive devitalized tissue or uncertain viability.
Wound Cleansing and Irrigation:
- Goal: Effective removal of bacteria and debris without harming viable tissue.
Recommended irrigants:
- Normal saline (0.9%) or tap water:
- Equally effective, safe, and cost-efficient.
- Suitable for most wounds, especially scalp and extremities.
- Pressure irrigation (7-8 psi):
- Achieved by attaching an 18-gauge needle to a 30-mL syringe.
- Essential for effective debris and bacterial removal.
- High-pressure irrigation (50-70 psi):
- Can significantly reduce bacterial load.
- Use with caution due to potential for tissue damage.
Avoid:
- Soaking wounds in antiseptic solutions (ineffective and harmful).
- Scrubbing wounds aggressively (tissue damage, increased infection risk).
- Detergent-containing cleansers in open wounds (toxic to tissue).
Special Considerations:
- Facial and scalp lacerations: Routine irrigation might not significantly impact infection rates or cosmetic outcomes; prioritize irrigation for wounds >5 cm or those with high-risk features.
Key ED Pitfalls and Best Practices:
- Pitfall: Using antiseptics directly in wounds increases infection risk due to tissue toxicity.
- Best Practice: Antiseptics for skin prep only; saline or tap water for wound irrigation.
- Pitfall: Razors for hair removal significantly elevate infection risk.
- Best Practice: Use electric clippers or scissors if hair removal is necessary.
- Pitfall: Inadequate drying time for antiseptics reduces efficacy.
- Best Practice: Strict adherence to recommended drying times (30 sec for CHG-alcohol, 2-3 min for povidone-iodine).
Quick Reference Table
| Procedure | Preferred Agent | Application | Special Notes |
|---|---|---|---|
| Intact Skin Procedures | Chlorhexidine-alcohol | Apply and dry for 30 sec | Avoid eyes and open wounds |
| Open Wound Procedures | Povidone-iodine (aqueous) | Apply and dry for 2-3 mins | Prevent direct wound contact |
| Post-Debridement | Dermacyn (Hypochlorous acid) | Only as post-clean irrigation |
D. Debridement
- Sharp removal of devitalized tissue, foreign material
- Avoid aggressive debridement in cosmetically sensitive areas (e.g., face)
IV. WOUND CLOSURE TECHNIQUES
A. Closure Methods
B. Suture Material and Size
C. Techniques
- Simple Interrupted – Versatile, allows tension adjustment
- Vertical Mattress – For eversion, moderate tension wounds
- Horizontal Mattress – High tension, fragile skin
- Running/Subcuticular – Cosmesis (face), low tension
🔧 Tip: Leave sutures long enough (~0.5-1 cm) for easy removal. Tie flat, secure knots with 3-1-1 technique.
V. POSTREPAIR WOUND CARE AND INSTRUCTIONS
A. General Instructions
- Keep dressing dry for first 24–48 hours
- After 24 hrs, wound can be gently washed with soap and water
- No immersion (baths, pools) until after suture removal
- Elevate extremity 24–48 hours to reduce edema and pain
- No hydrogen peroxide after scab formation (toxic to epithelium)
B. Signs of Infection
Educate patient to return for:
- Redness, warmth, increasing pain
- Pus or cloudy discharge
- Fever
- Red streaks (lymphangitis)
C. Suture Removal Timing
💡 Consider alternate suture removal (e.g., every-other stitch) before full removal to prevent dehiscence.
D. Scar Minimization
- Use Steri-Strips post-suture removal for 2–4 weeks
- Educate that the final scar maturation takes 6–12 months
- Avoid sun exposure; use sunscreen for 6 months
VI. INFECTION PREVENTION STRATEGIES
- Irrigate properly – Most important step to reduce infection
- Avoid closure in high-risk wounds until clean
- Antibiotic prophylaxis for: Bites (human, deep dog/cat) Open fractures Joint or tendon exposure Foot puncture through shoe (cover Pseudomonas) Immunocompromised patients
🧪 Most common pathogens: Staph aureus, Strep, Pasteurella (bites), Pseudomonas (plantar punctures)
VII. TETANUS PROPHYLAXIS
- TIG Dose: 250 IU IM
- Tdap preferred over Td in adults to boost pertussis immunity
VIII. SPECIAL WOUND TYPES
A. Scalp Wounds
- Often bleed heavily; use pressure or staples
- Irrigate if >5 cm or contaminated
- Hair apposition if wound <10 cm, not gaping, and clean
B. Nail Bed Injuries
- Use 6-0 absorbable sutures or tissue glue
- Replace nail as natural splint; secure with suture
- Apply volar splint, nonadherent dressing
C. Oral/Intraoral Wounds
- Rinse with warm salt water 3x/day
- Sutures: absorbable (e.g., chromic gut)
- No need for antibiotics unless contaminated
D. Over Joints
- Evaluate for joint capsule involvement
- Immobilize with splint
- Longer duration sutures (10–14 days)
IX- Antibiotic Prophylaxis in Wound Management: When and What to Use
✅ DO NOT use routine antibiotics for:
• Clean, simple, non-bite lacerations
• Evidence shows no benefit; may increase infection risk
✅ Use antibiotics when:
1. Through-and-Through Oral Lacerations
• Higher infection risk vs simple mucosal wounds
• Pen VK 500 mg BID × 5 days
• Consider in: immunocompromised, elderly, or unreliable follow-up
2. Gross Contamination or Crush Injuries
• Devitalized tissue, soil, or delayed presentation
• Cephalexin 500 mg QID × 5–7 days
• Cefazolin IV if inpatient
• Consider delayed primary closure
3. Open Fractures
• Start ASAP — delay increases infection risk
• Grade I/II: Cefazolin IV × 24–48 hrs
• Grade III / contaminated:
• Ceftriaxone IV ± Gentamicin (or Metronidazole if soil/fecal) × 72 hrs
• Use Clindamycin if cephalosporin allergic
4. Gunshot Wounds
• Low-velocity, closed fractures: No antibiotics needed
• High-velocity or open fractures:
• Cefazolin IV ± Gentamicin for 48–72 hrs
5. Cat Bites
• Deep, puncture wounds; 10–40% infection rate
• Amoxicillin-clavulanate 875/125 mg BID × 7 days
• Covers Pasteurella, Strep, Staph
6. Dog Bites (Selective)
• Not routine — use only if:
• Wound to hand, face, or foot
• Puncture, crush, deep wound
• Comorbidities: DM, immunosuppressed
• Amoxicillin-clavulanate 875/125 mg BID × 5–7 days
7. Human Bites / “Fight Bites”
• Always prophylax — high polymicrobial risk
• Amoxicillin-clavulanate 875/125 mg BID × 7 days
• If signs of infection: consider Ampicillin-sulbactam IV or admit
8. Puncture Wounds of the Foot
• High-risk for Pseudomonas osteomyelitis (esp. through sneakers)
• Levofloxacin 500–750 mg daily if concern for Pseudomonas
• For Staph/Strep only: Cefalexin or Dicloxacillin
• Suspected MRSA? Use TMP-SMX or Doxycycline
• Always arrange early follow-up
⚠️ Special Considerations
• Prosthetic joints, endocarditis risk, or severe immunosuppression:
• Consider prophylaxis on a case-by-case basis — not routine
• Avoid unnecessary use due to:
• Resistance, C. diff, candidiasis, adverse reactions, cost
X. CLINICAL PEARLS
- Always inspect the full depth of the wound before closure
- Check for foreign bodies, especially in dirty wounds or glass injuries
- Do not shave eyebrows or scalp – cut hair, don’t shave
- Tissue adhesives are safe and preferred for clean, low-tension, short wounds
- Avoid systemic antibiotics unless specific indications
- To minimize the risk of scar formation, sutures should be removed as soon as possible. .
- Educate patients that scars are inevitable but can be minimized with care
- Always dry the wound field before applying adhesive or tape
- Mark the edge of erythema with a pen for infection monitoring
- Use the wet-to-dry gauze trick for crusted wounds before suture removal
- Two-layer closure can dramatically reduce scar width in high-tension areas
- Instruct patients with facial wounds to sleep head elevated for 48 hrs to reduce edema
📗 Wound Management Flowchart for Emergency Physicians
1. INITIAL PATIENT ASSESSMENT
• ⬜ Mechanism of injury (blunt, sharp, bite, puncture)
• ⬜ Time since injury (<6–12 hrs? face <24 hrs?)
• ⬜ Wound contamination (soil, feces, saliva, glass, etc.)
• ⬜ Location (face, joint, scalp, extremity)
• ⬜ Tetanus status? Allergies?
➡ Proceed to Wound Examination
2. PHYSICAL EXAMINATION
• ⬜ Assess wound depth
• ⬜ Check for tendon/joint involvement (active/passive ROM)
• ⬜ Neurovascular status distal to wound
• ⬜ Identify high-risk features (crush, stellate, avulsion)
➡ If suspicion of FB or fracture ➡ Go to Imaging
➡ Otherwise ➡ Wound Preparation
3. IMAGING (if indicated)
• ⬜ X-ray for fractures or radiopaque foreign body
• ⬜ Ultrasound for glass, wood
• ⬜ CT for deep or critical area injuries
➡ Then ➡ Wound Preparation
4. WOUND PREPARATION
• ⬜ Achieve hemostasis (pressure, lidocaine + epi, tourniquet)
• ⬜ Irrigate with high-pressure saline/tap water (~50–100 mL/cm)
• ⬜ Debride nonviable tissue
• ⬜ Explore full depth
➡ Now make Closure Decision
5. CLOSURE DECISION
• ✅ Primary Closure
• Clean wound
• <12 hrs (face <24 hrs)
• No signs of infection
• ⏳ Delayed Primary Closure
• Contaminated or old wound
• Close in 3–5 days if clean on recheck
• ❌ Secondary Intention
• Infected, dirty, puncture, animal bite (especially hands)
➡ If closing ➡ Choose Closure Method
6. CLOSURE METHOD
• ⬜ Sutures (standard)
• ⬜ Staples (scalp, trunk)
• ⬜ Glue (clean, low-tension areas)
• ⬜ Steri-Strips (superficial or reinforce sutures)
• ⬜ Hair apposition (scalp with >3 cm hair)
➡ Then ➡ Post-Care Plan
7. POST-CARE INSTRUCTIONS
• ⬜ Elevate extremity (24–48 hrs)
• ⬜ Keep dry x 24 hrs, then gentle washing
• ⬜ Signs of infection: redness, warmth, pus, fever, streaking
• ⬜ Suture removal plan:
• Face: 3–5 days
• Scalp: 7–10 days
• Trunk/extremity: 10–14 days
• Joints: 14 days
➡ Final Step ➡ Tetanus & Antibiotics
8. TETANUS & ANTIBIOTIC CONSIDERATION
• ⬜ Tdap if >10 yrs or unknown status
• ⬜ TIG if <3 doses and dirty wound
• ⬜ Antibiotics if:
• Bite, puncture through shoe
• Exposed tendon/joint
• Diabetic/immunocompromised
• Gross contamination
✅ Done! Wound Managed Safely.
