Overview
Acute Wound Care
Quick Reference
Critical Alerts
- Control hemorrhage first: Direct pressure, tourniquet if needed
- Assess neurovascular status: Before and after repair
- Evaluate for underlying structures: Tendons, nerves, vessels, bone
- Tetanus prophylaxis: Update if needed
- Wound age matters: Primary closure typically within 6-24 hours
- High-risk wounds may need antibiotics: Bites, crush injuries, contaminated
Wound Closure Options
| Method | Indications |
|---|---|
| Sutures | Most lacerations; best for tension |
| Staples | Scalp, trunk; faster |
| Tissue adhesive (glue) | Low-tension, superficial, clean |
| Steri-strips | Low-tension, superficial |
| Secondary intention | Contaminated, delayed presentation, abscess |
Emergency Treatments
| Intervention | Details |
|---|---|
| Hemostasis | Direct pressure ± tourniquet |
| Irrigation | NS or water, high volume |
| Wound exploration | Assess depth, structures |
| Local anesthesia | Lidocaine ± epinephrine |
| Closure | Sutures, staples, or adhesive |
| Tetanus prophylaxis | If indicated |
| Antibiotics | For high-risk wounds |
Definition
Overview
Acute wound care involves the evaluation, cleaning, and closure of skin and soft tissue injuries. The goals are to control bleeding, prevent infection, promote healing, and minimize scarring. Proper assessment of wound characteristics guides closure method, need for antibiotics, and follow-up.
Classification
By Mechanism:
| Type | Features |
|---|---|
| Laceration | Cut from sharp or blunt force |
| Abrasion | Superficial skin loss (scrape) |
| Puncture | Deep, narrow wound |
| Avulsion | Tissue torn away |
| Crush | Tissue damage from compression |
By Contamination:
| Type | Examples |
|---|---|
| Clean | Sharp cut, low bacterial load |
| Contaminated | Soil, feces, organic material |
| Infected | Pus, signs of infection |
Epidemiology
- Common: ~12 million ED visits/year for lacerations
- Peak age: Children and young adults
- Common locations: Face, scalp, hands, legs
Pathophysiology
Wound Healing Phases
| Phase | Timing | Events |
|---|---|---|
| Hemostasis | Immediate | Clot formation |
| Inflammatory | 0-4 days | Neutrophils, macrophages, debridement |
| Proliferative | 4-21 days | Granulation tissue, epithelialization |
| Remodeling | 21 days - 1 year | Collagen remodeling, scar maturation |
Factors Affecting Healing
| Factor | Effect |
|---|---|
| Infection | Delays healing |
| Diabetes | Impaired healing |
| Immunosuppression | Impaired healing |
| Contamination | Increases infection risk |
| Blood supply | Poor perfusion impairs healing |
| Wound tension | Increases dehiscence risk |
Clinical Presentation
Assessment
History:
Physical Examination:
| Assessment | Details |
|---|---|
| Wound characteristics | Location, length, depth, edges |
| Bleeding | Active? Controlled? |
| Foreign body | Visible or suspected |
| Underlying structures | Tendon, nerve, vessel, bone, joint |
| Neurovascular status | Sensation, motor, pulses |
| Contamination | Debris, soil |
Mechanism of injury (sharp, blunt, crush, bite)
Common presentation.
Time of injury
Common presentation.
Tetanus status
Common presentation.
Allergies (to anesthetics, adhesives)
Common presentation.
Medications (anticoagulants)
Common presentation.
Medical conditions (diabetes, immunocompromise)
Common presentation.
Contamination (soil, feces)
Common presentation.
Red Flags
Concerning Features
| Finding | Concern | Action |
|---|---|---|
| Arterial bleeding | Major vessel injury | Pressure, tourniquet, vascular surgery |
| Tendon injury | Functional deficit | Hand surgery referral |
| Nerve injury | Sensory/motor deficit | Document, refer if indicated |
| Joint involvement | Septic arthritis risk | Orthopedics, antibiotics |
| Crush injury | Compartment syndrome | Monitor, consider fasciotomy |
| Bite wound | High infection risk | Antibiotics, consider rabies |
| Heavily contaminated | Infection risk | Delayed closure, antibiotics |
Differential Diagnosis
Consider Other Injuries
| Diagnosis | Features |
|---|---|
| Fracture | Deformity, crepitus, X-ray |
| Tendon injury | Weakness, inability to move |
| Nerve injury | Numbness, weakness |
| Vascular injury | Pulseless, expanding hematoma |
| Compartment syndrome | Pain out of proportion, passive stretch pain |
| Foreign body | History, X-ray, ultrasound |
Diagnostic Approach
Imaging
X-Ray:
| Indication | Reason |
|---|---|
| Suspected foreign body | Glass, metal |
| Suspected fracture | Mechanism, exam |
| Over joint | Rule out joint involvement |
Ultrasound:
- Foreign body detection (non-radiopaque)
- Abscess evaluation
Wound Exploration
- Visualize throughout range of motion (especially hands)
- Document tendon, nerve, vessel involvement
- Identify foreign bodies
Treatment
Principles
- Hemostasis: Control bleeding
- Anesthesia: For patient comfort
- Irrigation: Clean the wound
- Debridement: Remove devitalized tissue
- Closure: Appropriate method
- Tetanus prophylaxis: If indicated
- Antibiotics: For high-risk wounds
Hemostasis
| Method | Indication |
|---|---|
| Direct pressure | First-line |
| Tourniquet | Extremity, uncontrolled bleeding |
| Electrocautery | Surgical hemostasis |
| Topical hemostatic agents | Adjunct |
Anesthesia
Local Infiltration:
| Agent | Max Dose (Plain) | Max Dose (With Epi) |
|---|---|---|
| Lidocaine 1% | 4.5 mg/kg | 7 mg/kg |
| Bupivacaine 0.25% | 2.5 mg/kg | 3 mg/kg |
Buffering: Add sodium bicarbonate (1:9 ratio) to reduce pain
Topical Anesthesia:
- LET gel (lidocaine, epinephrine, tetracaine): Face, scalp
- EMLA: Intact skin
Nerve Blocks:
- Digital block for fingers/toes
- Regional blocks for larger areas
Irrigation
| Parameter | Recommendation |
|---|---|
| Solution | Normal saline or tap water |
| Volume | ≥50 mL/cm wound length |
| Pressure | 8-12 psi (syringe with splash shield) |
Avoid: Hydrogen peroxide, povidone-iodine (cytotoxic)
Debridement
- Remove devitalized tissue
- Trim ragged wound edges
- Excise heavily contaminated tissue
Wound Closure
Primary Closure (Most clean wounds):
| Method | Indications |
|---|---|
| Sutures | Tension, deep wounds, cosmetic areas |
| Staples | Scalp, trunk; faster |
| Tissue adhesive | Low-tension, superficial, clean |
| Steri-strips | Low-tension, minimal bleeding |
Delayed Primary Closure (3-5 days):
- Contaminated wounds
- Wounds >24 hours old
Secondary Intention:
- Heavily contaminated
- Infected wounds
- Abscesses (after I&D)
Suturing Technique
Suture Selection:
| Location | Absorbable (Deep) | Non-Absorbable (Skin) |
|---|---|---|
| Face | 5-0 or 6-0 Vicryl | 6-0 Nylon |
| Scalp | — | Staples or 3-0 Nylon |
| Trunk | 3-0 or 4-0 Vicryl | 4-0 Nylon |
| Extremity | 3-0 or 4-0 Vicryl | 4-0 Nylon |
| Hand | 4-0 or 5-0 Vicryl | 5-0 Nylon |
Suture Removal Timing:
| Location | Days |
|---|---|
| Face | 5-7 |
| Scalp | 7-10 |
| Trunk | 10-14 |
| Extremity | 10-14 |
| Over joint | 14 |
Tetanus Prophylaxis
| Wound Type | <3 Tdap Doses or Unknown | ≥3 Doses, Last <5 Years | ≥3 Doses, Last 5-10 Years | ≥3 Doses, Last >0 Years |
|---|---|---|---|---|
| Clean, minor | Tdap | None | None | Tdap |
| Other wounds | Tdap + TIG | None | Tdap | Tdap |
Antibiotic Prophylaxis
Indicated For:
| Wound Type | Antibiotic |
|---|---|
| Human/Animal bites | Amoxicillin-clavulanate 875/125 BID × 3-5 days |
| Open fractures | Cefazolin ± Gentamicin |
| Heavily contaminated | Amoxicillin-clavulanate or TMP-SMX |
| Through-and-through oral lacerations | Amoxicillin-clavulanate |
| Wounds in immunocompromised | Consider |
NOT Routinely Indicated:
- Simple, clean lacerations
Disposition
Discharge Criteria
- Bleeding controlled
- Wound adequately cleaned and closed
- Tetanus updated
- Patient educated on wound care
- Follow-up arranged
Referral
| Indication | Referral |
|---|---|
| Tendon injury | Hand/Plastic surgery |
| Nerve injury (motor) | Specialist |
| Vascular injury | Vascular surgery |
| Open fracture | Orthopedics |
| Complex facial laceration | Plastic surgery |
| Wound requiring flap/graft | Plastic surgery |
Follow-Up
| Situation | Follow-Up |
|---|---|
| Simple laceration | PCP for suture removal |
| Bite wound | 24-48 hours wound check |
| High-risk wound | 24-48 hours wound check |
Patient Education
Wound Care Instructions
- Keep wound clean and dry for first 24 hours
- After 24 hours, gently wash with soap and water
- Apply thin layer of antibiotic ointment (optional)
- Change dressing daily or if wet/dirty
- Elevate if extremity wound
Warning Signs to Return
- Increasing redness, swelling, or warmth
- Pus or foul-smelling discharge
- Fever
- Red streaks spreading from wound
- Wound opening up
- Numbness or weakness
Special Populations
Children
- May need sedation for repair
- Topical anesthesia (LET) helpful
- Tissue adhesive often preferred
Elderly
- Thin, fragile skin
- Consider Steri-strips or tissue adhesive
- Higher infection risk (diabetes, immunocompromise)
Anticoagulated Patients
- Higher bleeding risk
- May need longer pressure
- Consider reversal for severe bleeding
Quality Metrics
Performance Indicators
| Metric | Target | Rationale |
|---|---|---|
| Irrigation documented | 100% | Infection prevention |
| Tetanus assessed | 100% | Standard of care |
| Neurovascular exam documented | 100% | Detect injury |
| Antibiotic for bites | >0% | Guideline adherence |
Documentation Requirements
- Mechanism and timing
- Wound characteristics
- Neurovascular status
- Foreign body search
- Closure method
- Tetanus status
- Discharge instructions
Key Clinical Pearls
Diagnostic Pearls
- Explore wounds throughout range of motion: Especially hands
- Suspect foreign body if mechanism suggests: X-ray for glass/metal
- Tendon injury can be partial: Assess against resistance
- Check neurovascular status before and after anesthesia
- Wound age affects closure: Generally < 6-24 hours for primary
Treatment Pearls
- Irrigation is key: High volume, low pressure
- Tap water is acceptable: For irrigation
- Epinephrine is safe on fingers/toes: Lidocaine with epi
- Tissue adhesive needs dry, low-tension wound: Not for hands
- Prophylactic antibiotics for bites, not clean lacerations
- Tetanus: Check vaccine status
Disposition Pearls
- Most lacerations can be discharged: With clear instructions
- Refer complex tendon, nerve, or facial wounds: Specialist
- Follow-up for bite wounds: High infection risk
- Suture removal based on location: Face 5-7d, extremities 10-14d
References
- Singer AJ, et al. Current Management of Acute Cutaneous Wounds. N Engl J Med. 2008;359(10):1037-1046.
- Hollander JE, et al. Wound Closure. Annals of Emergency Medicine. 2003;42(6):640-650.
- Lammers RL. Principles of Wound Management. In: Roberts and Hedges' Clinical Procedures in Emergency Medicine. 7th ed. 2019.
- Quinn JV, et al. A randomized, controlled trial comparing a tissue adhesive with suturing in repair of pediatric facial lacerations. Ann Emerg Med. 1993;22(7):1130-1135.
- Edlich RF, et al. Innovations in wound closure methodology. J Emerg Med. 2001;20(1):45-64.
- Zehtabchi S, et al. The Role of Antibiotics in the Management of Open Fractures. Emerg Med Clin North Am. 2018;36(1):185-200.
- CDC. Tetanus Vaccination. 2024.
- UpToDate. Minor wound preparation and closure. 2024.