Chapter 47: Postrepair Wound Care

Postoperative care begins immediately after laceration repair in the ED with gentle cleansing using normal saline or clean (tap) water to remove any residual blood products or contamination. Additional considerations include dressings, topical antibiotics, edema reduction techniques, prophylactic antibiotics, tetanus prophylaxis, and wound drains. Before ED release, give the patient instructions regarding wound care and cleansing, pain control, signs of infection, follow-up dates, and short-term and long-term cosmetic expectations.

Postoperative wound dressing should be tailored to both the type of wound and method of wound closure. Most sutured or stapled lacerations should be covered with a protective, nonadherent dressing for 24 to 48 hours. Maintaining a moist environment increases the rate of re-epithelialization, and occluded wounds heal faster than those exposed to air.^1,2,3 Conversely, leaving lacerations exposed to air may result in a slightly lower healing rate but does not result in an increased rate of infection.⁴

Useful dressings are semipermeable films manufactured from transparent polyurethane or similar synthetic films coated on one surface with a water-resistant hypoallergenic adhesive. They are highly elastic, conform easily to body parts, and are generally resistant to shear and tear. They are permeable to moisture vapor and oxygen but impermeable to water and bacteria. Common brands of semipermeable wound dressings are OpSite Post-Op^® (Smith & Nephew PLC, London, UK), Bioclusive^® (Johnson & Johnson, New Brunswick, NJ), and Tegaderm^® (3M, St. Paul, MN). The disadvantages of these products are that they cannot absorb large amounts of fluid and exudate, and they do not adhere well to very moist wounds.

Topical antibiotic creams and ointments are an alternative to the use of commercial dressings to maintain a moist environment. As an added benefit, topical antibiotics may help reduce infection rates and may also prevent scab formation.^5,6,7 However, patients whose lacerations are closed with tissue adhesives should not use topical ointments or creams because they will loosen the adhesive and may result in dehiscence. Tissue adhesives serve as their own antimicrobial barrier and occlusive dressing; wounds closed with tissue adhesives do not require supplementary dressings.

Wounds with associated soft tissue contusion should have the injury site elevated above the patient's heart for 24 to 48 hours to limit accumulation of fluid in the wound interstitial spaces. Wounds with little edema heal more rapidly than those with marked edema. Pressure dressings can be used to minimize the accumulation of intercellular fluid in the subcutaneous space. Pressure dressings are useful for ear and scalp lacerations (see chapter 42, "Face and Scalp Lacerations"). Pressure dressing applied to the ear can prevent auricular hematoma formation and reduce the subsequent likelihood of a cauliflower deformity. Vaseline gauze or Xeroform^® (Kendall Healthcare, Mansfield, MA) dressings are easy to mold around the ear. For large scalp lacerations that have a tendency to bleed, short-term use of a pressure dressing will limit subcutaneous hematoma formation. However, excessive pressure should be avoided in all pressure dressings, especially in the extremities where they may compromise circulation. Consider a short period of splinting with large lacerations over joints to reduce pain, limit tension on the wound, minimize swelling, and promote healing.

Prophylactic oral antibiotics are not recommended except for select circumstances^8,9,10,11 based on guiding principles: the degree of bacterial contamination, the presence of infection-potentiating factors (e.g., soil), the mechanism of injury, and the presence or absence of host predisposition to infection.^12,13,14 Compulsive wound cleansing is far more important than antibiotics to reduce postrepair wound infection.^15,16

Prophylactic antibiotics are recommended for human bites, cat bites, deep dog bite puncture wounds, bite wounds to the hand, open fractures, and wounds with exposed joints or tendon.^{12,13,14,15,16,17} Also, consider prophylactic antibiotics after wound closure in a lymphedematous area.^18,19

The risk of bacteremia during care of grossly contaminated lacerations in the ED is unknown, but is likely to be small.²⁰ However, some patients who have structural heart disease, arteriovenous hemodialysis fistulas, prosthetic joints, cerebrospinal fluid shunts, vascular grafts, or other permanent indwelling "hardware" may trap bacteria from the blood stream and develop infections in the above-mentioned organs or devices. There is no evidence for preprocedure antibiotic prophylaxis to prevent bacteremic spread of infection from manipulation of a contaminated site. If the physician chooses to use antibiotic prophylaxis for the management of a heavily contaminated wound in a patient with these conditions or devices, give a single dose of an IV antibiotic before the wound is manipulated.

Antibiotics used for postrepair prophylaxis are similar to those used for treatment of established infections (Table 47-1).⁸ For most patients, a first-generation cephalosporin or antistaphylococcal penicillin (e.g., dicloxacillin) is reasonable. Although methicillin-resistant Staphylococcus aureus has become a common cause of skin and soft tissue infections, postinjury antibiotic prophylaxis to cover this pathogen does not appear necessary.⁸ Amoxicillin-clavulanate is the preferred prophylactic treatment for high-risk mammalian bite wounds.^12,13 For open fractures or joints, a parenteral antistaphylococcal agent and an aminoglycoside should be used.¹⁷ There is no evidence that patients who receive antibiotic prophylaxis benefit from an initial IV dose. Antibiotic prophylaxis continues for 3 to 5 days for nonbite injuries and 5 to 7 days for bite wounds. Patients at high risk for infection should be told to return for a wound check in 24 to 48 hours.

Two thirds of the recent tetanus cases in the United States follow lacerations, puncture wounds, and crush injuries (see chapter 156, "Tetanus"),²¹ so, as part of wound care, ask about previous tetanus immunizations. Recommendations for tetanus prophylaxis are based on the condition of the wound and the patient's immunization history (Table 47-2). Consider passive immunization with tetanus immune globulin for those without a history of a primary series of three tetanus immunizations. Because of the emergence of pertussis infections, Tdap (containing the acellular pertussis vaccine) should replace a single dose of tetanus and diphtheria toxoids for adults who have not previously received a dose of Tdap (either in the primary series, as a booster, or for wound management).²² The 2013 Advisory Committee on Immunization practices recommend either Tdap or Boostrix^® for those >65 years old.

The only contraindication to tetanus toxoid is a history of neurologic or severe systemic reaction after a previous dose. Local self-limited reactions, such as erythema, induration, and pain at the injection site, are common after tetanus vaccination. These local side effects do not preclude future tetanus immunization. Exaggerated local reactions occur occasionally after tetanus toxoid and involve extensive pain and swelling of the entire extremity. Exaggerated local reactions occur most often in adults with high serum tetanus antitoxin levels who have received frequent doses of tetanus toxoid. Such patients should not receive tetanus toxoid more frequently than every 10 years. Severe systemic reactions to tetanus immunization include generalized urticaria, anaphylaxis, or neurologic complications, including peripheral neuropathy and Guillain-Barré syndrome. A severe allergic reaction, including acute respiratory distress or cardiovascular collapse after a dose of tetanus toxoid, is a contraindication to further immunization. A moderate or severe acute illness is also a reason to defer routine immunization, although a minor illness is not. If the use of a tetanus toxoid is contraindicated, consider passive immunization with tetanus immune globulin in a tetanus-prone wound.

Sutured or stapled wounds can be gently washed and cleansed with tap water as early as 8 hours after closure without an increase in infection rate.^23,24 Using soap and tap water to cleanse lacerations will not increase the infection rate.²⁵ Use gentle blotting to dry the area; aggressive wiping could cause wound dehiscence. For routine wounds, tell patients to remove dressings after 24 hours, cleanse the wound, and examine it for signs of infections. In certain special situations, the dressing should remain undisturbed for 4 to 5 days until the patient is reevaluated by the physician.

Thereafter, daily cleansing ensures that the patient examines the laceration for early signs of infection. Patients should observe the wound for redness, warmth, swelling, and drainage, and contact a physician if such signs develop. Standardized wound-care instructions improve patient compliance and understanding.²⁶

Reapplication of topical antibiotics for 3 to 5 days will decrease scab formation, thereby preventing wound edge separation. Patients with tissue adhesives may shower but should avoid bathing and swimming because prolonged moisture will loosen the adhesive bond and result in slightly earlier sloughing of the adhesive.²⁷

Drains are placed in wounds and surgical incisions under three circumstances: (1) to drain interstitial fluid or blood and prevent accumulation into a seroma or hematoma, respectively; (2) to maintain a tract so pus can drain from an infected area; or (3) to allow for drainage from a contaminated location and prevent an abscess from forming.²⁸ Drains allow for near-complete wound closure in circumstances where closure would otherwise be impeded by fluid, pus, or blood accumulation. Drains can be categorized as (1) gauze packing to maintain open drainage and collect the exudate, (2) open systems using soft rubber (e.g., Penrose drain) or silicone tubing to direct drainage onto external gauze dressings, or (3) closed systems using silicone tubing and attached fluid collection reservoirs. Drains can be placed either through the suture line of the initial wound or incision or through an adjacent incision made specifically for drain access.

The most common type of wound drain placed in the ED is ¹/₄- to 1-in. (0.6- to 2.5-cm) ribbon gauze used to pack an abscess cavity after incision and drainage. Dressings over draining abscesses may initially require frequent changes. The internal packing should be replaced daily as long as the wound continues to produce exudate. Once the purulence stops, internal packing is no longer required, and daily cleaning with external dressing changes should continue until enough granulation tissue forms and the wound stops draining. Maintaining a moist, clean environment promotes wound healing. Equivalent outcomes in otherwise healthy patients with subcutaneous abscesses can be obtained with alternatives to traditional packing: no packing,^29,30,31 incision and loop drainage,^32,33,34,35 modified Pezzar catheter,³⁶ and silver-containing hydrofiber dressing.³⁷

Open drainage using soft rubber tubing (e.g., Penrose drains) has been used for years to drain infected or contaminated wounds that have been partially or completely closed. A safety pin placed through the tubing can prevent the drain from inappropriately advancing into the wound. As the exudate diminishes and the wound heals, the Penrose drain can be pulled out a portion each day to allow the wound to heal from the "bottom up." The disadvantage of open drains, such as the Penrose, is the access they provide for bacteria into the wound.

For many wounds, especially postsurgical wounds, closed drainage systems have replaced open wound drains. The collection reservoir for closed drainage systems often has a self-inflating ability so it can be squeezed before attachment to the tubing in order to place vacuum suction in the wound to enhance drainage (e.g., Jackson-Pratt^®, Cardinal Health, Dublin, OH; Hemovac^®, Zimmer, Inc., Warsaw, IN; ConstaVac^®, Stryker Corp., Kalamazoo, MI). Assessment of the tubing and emptying of the reservoir should be done with sterile technique (similar to dressing changes for indwelling lines). The reservoir may require emptying several times per day, depending on the drainage volume. It is common practice to remove closed drains when the amount of fluid drained each day reaches low levels (typically 30 to 40 mL per day). If a drainage tube is accidentally pulled out, it should not be reinserted. In many surgical settings, the benefit of closed drainage systems is unproven.^38–47

Vacuum-assisted closure or negative-pressure wound therapy is a method used to close difficult wounds.^48,49,50,51 The vacuum-assisted closure technique consists of insertion of an open-cell foam sponge into the wound, sealing with an adhesive drape, and subsequent application of negative, subatmospheric pressure, usually at 125 mm Hg.⁵⁰ Vacuum-assisted closure promotes wound healing by removing localized edema, which improves vascular and lymphatic flow by reducing bacteria density, by promoting angiogenesis, and by increasing granulation tissue formation.^48,49,50 There is no proven role for vacuum-assisted closure in the management of lacerations closed in the ED.

Abrasions and some lacerations can be quite painful. Patients should be educated regarding the expected degree of pain and measures that may help reduce pain. Splints can be used to reduce swelling and pain for extremity lacerations. Appropriate analgesic medications and anti-inflammatory agents will help control pain. The pain from lacerations generally decreases after the initial 48 hours, and opioid analgesics are rarely necessary after that time. Patients with concurrent contusions (such as victims of motor vehicle crashes) will often report worsening pain 24 to 48 hours after the initial injury.

Tell patients when and with whom to follow up for suture removal or wound examination.²⁶ Sutures or staples in most locations should be removed after approximately 7 to 10 days (Table 47-3). Remove facial sutures in 3 to 5 days to avoid formation of unsightly sinus tracts and hatch marks.⁵² Sutures over the joints or in the hands should be left in place for 10 to 14 days, as they may be subject to increased tension during movement. When removing sutures, avoid applying tension in a direction that would tend to cause dehiscence. Debride any scab or crusting over the sutures before suture removal by gently applying gauze soaked with hydrogen peroxide. Then, grasp the suture at the knot with the forceps for removal (Figure 47-1). Use scissors or a #12 blade to cut the sutures. Skin staples are removed with a specific device that deforms the center and extracts the legs from the skin (Figure 47-2).

Tissue adhesives will slough off, typically within 5 to 10 days of application, and do not usually require removal. Tell the patient to avoid picking at the tissue adhesive or scrubbing the area or exposing it to water for more than brief periods. If tissue adhesives remain on the skin for prolonged periods, antibiotic ointment, petroleum jelly, or bathing can accelerate removal. When adhesive tapes are used, they can be removed by gentle peeling away from the skin, starting at one end of the laceration and proceeding along and parallel to the wound, avoiding pulling across or perpendicular to the wound.

Scheduled "wound checks" might be useful in high-risk patients, high-risk wounds, or patients unable to identify signs of infection. Because many healing wounds may develop erythema and patients are not able to correctly identify wound infections, do not prescribe antibiotics without a reevaluation.⁵³ Patients who require further tetanus immunization to complete their primary series should have the second dose 1 to 2 months after the first dose, and the third dose 6 to 12 months after the second dose.

Educate patients about the expected outcome before wound closure. Re-enforce the message at the time of suture or staple removal or wound follow-up. Tell patients that all traumatic lacerations result in some scarring and that short-term cosmetic appearance is not highly predictive of the ultimate cosmetic outcome.⁵⁴ Healing lacerations and abrasions should not be exposed to direct sunlight, because sun exposure can result in permanent hyperpigmentation.⁵⁵ Protect injured skin with a sun-blocking agent for 6 to 12 months after injury.