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.
Wound dressings provide a moist environment that promotes epithelialization and speeds healing. Semipermeable films such as OpSite® 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.
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 11).
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 15), intraoral lacerations (see Chapter 11), open fractures, and wounds with exposed joints or tendons (see Chapters 12, 13). 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.
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 16-1 for a summary of recommendations for tetanus prophylaxis).
Table 16-1 Recommendations for Tetanus Prophylaxis |Favorite Table|Download (.pdf)
Table 16-1 Recommendations for Tetanus Prophylaxis
|Clean Minor Wounds||All Other Wounds*|
|History of Tetanus Immunization||Administer Tetanus Toxoid†||Administer TIG‡||Administer Tetanus Toxoid||Administer TIG|
|<3 or uncertain doses||Yes||No||Yes||Yes|
|Last dose within 5 y||No||No||No||No|
|Last dose within 5–10 y||No||No||Yes||No|
|Last dose >10 y||Yes||No||Yes||No|