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324 SECTION 6: Wound Management B virus, also called herpes B, is caused by Macacine herpesvirus 1 and can be transmitted by bites from monkeys and other nonhuman primates, although only monkeys of the macaque family serve as the natural reservoir for B virus infection. 94-97 Human infection with B virus causes myelitis and hemorrhagic encephalitis, with a case fatality rate of 70%. Those at greatest risk for B virus infection are veterinarians, laboratory workers, and others who have close contact with macaques or monkey cell cultures. After a bite or wound from a macaque, immediately and thoroughly wash and gently scrub the area or wound with soap, concentrated solution of detergent, povidoneiodine, or chlorhexidine and water for 15 minutes, and then irrigate the washed area with running water for 15 to 20 minutes to reduce the chance of infection. Consultation with an infectious disease expert is strongly advised before beginning antiviral therapy. The Centers for Disease Control and Prevention maintains a website with current B virus information at (http://www.cdc.gov/herpesbvirus/index.html). Acyclovir or valacyclovir started immediately after injury can prevent or ameliorate this illness. Viral hepatitis and HIV can both be transmitted by a human bite, although HIV viral concentration in nonbloody saliva is thought to be relatively low. A protocol similar to that for an occupational needle stick injury should be used when a patient sustains a bite from a high-risk source (see Chapter 155, “Human Immunodeficiency Virus Infections”). REFERENCES The complete reference list is available online at www.TintinalliEM.com. Postrepair Wound Care Adam J. Singer Judd E. Hollander Joseph Stephan Stapczynski INTRODUCTION 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 consider ations include dressings, topical antibiotics, edema reduction tech niques, 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. WOUND DRESSINGS Postoperative wound dressing should be tailored to both the type of wound and method of wound closure. Most sutured or stapled lacera tions should be covered with a protective, nonadherent dressing for 24 to 48 hours. Maintaining a moist environment increases the rate of reepithelialization, and occluded wounds heal faster than those exposed to air. 1-3 Conversely, leaving lacerations exposed to air may result in a slightly lower healing rate but does not result in an increased rate of infection. 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).

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. 5-7 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. EDEMA REDUCTION Instruct patients to elevate the injury site for 24 to 48 hours when soft tissue contusion is present to limit accumulation of fluid in the wound area. 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”). For large scalp lacerations that have a tendency to bleed, short-term use of a pressure dressing will limit subcutaneous hematoma formation. Avoid excessive pressure in all pressure dressings, especially in the extremities where they may compromise circulation. Tube gauze dressing applied to fingers or toes should not be twisted at the base of the digit; such twisting may create a tourniquet and lead to distal ischemia. 8,9 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 ANTIBIOTICS Prophylactic oral antibiotics are not recommended except for select circumstances10-13 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 predis position to infection. 14-17 Compulsive wound cleansing is far more important than antibiotics to reduce postrepair wound infection.16,17 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 (see Chapter 46, “Puncture Wounds and Bites, ” and Chapter 267, “Initial Evaluation and Management of Orthopedic Injuries”). 14-16,18-20 Also, consider prophylactic antibiotics after wound closure in a lymphedematous area. 20,22 The risk of bacteremia during care of grossly contaminated lacera tions in the ED is unknown but is likely to be small. 21 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 bloodstream and develop infections in the previously mentioned organs or devices. There is no evidence for preprocedure antibiotic prophylaxis to prevent bacteremic spread of infection from manipulation of a con taminated site. Administer a single dose of an IV antibiotic before the wound is manipulated when antibiotic prophylaxis is desired during the management of a heavily contaminated wound in patients with these conditions or devices.

ibiotic prophylaxis to prevent bacteremic spread of infection from manipulation of a con taminated site. Administer a single dose of an IV antibiotic before the wound is manipulated when antibiotic prophylaxis is desired during the management of a heavily contaminated wound in patients with these conditions or devices. Antibiotics used for postrepair prophylaxis are similar to those used for treatment of established infections ( Table 47-1). 10 Oral administration is adequate for the initial dose, and there is no evidence that the parenteral route is better. Antibiotic prophylaxis continues for 3 to 5 days for nonbite injuries and 5 to 7 days for bite wounds. Although methicillin-resistant Staphylococcus aureus has become a common cause of skin and soft tissue infections, postinjury antibi otic prophylaxis to cover this pathogen does not appear necessary. Amoxicillin-clavulanate is the preferred prophylactic treatment for mammalian bite wounds. 14,15 For open fractures or joints, a parenteral first-generation cephalosporin should be used with an aminoglycoside added if extensive soft tissue injury is present. CHAPTER Tintinalli_Sec06_p0267-0328.indd 324 8/2/19 7:16 PM

. Amoxicillin-clavulanate is the preferred prophylactic treatment for mammalian bite wounds. 14,15 For open fractures or joints, a parenteral first-generation cephalosporin should be used with an aminoglycoside added if extensive soft tissue injury is present. CHAPTER Tintinalli_Sec06_p0267-0328.indd 324 8/2/19 7:16 PM CHAPTER 47: Postrepair Wound Care 325 TETANUS PROPHYLAXIS Tetanus can occur when lacerations, puncture wounds, and crush injuries are contaminated with Clostridium tetani spores (see Chapter 157, “Tetanus”). Most cases of tetanus in the United States occur in patients who are inadequately vaccinated. 24 As part of wound care, ask the patient about previous tetanus immunizations. Recommendations for postinjury tetanus prophylaxis are based on the condition of the wound and the patient’s immunization history (Table 47-2). 25 Because of the emergence of pertussis infections, Tdap (tetanus, diphtheria, and pertussis; containing the acellular pertussis vaccine) should be used in adults who have not previously received a dose of Tdap (either in the primary series, as a booster, or for wound management) or are >65 years old. The only contraindication to tetanus toxoid is a history of neu rologic 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 sys temic 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 teta nus toxoid, is a contraindication to further immunization. If the use of a tetanus toxoid is contraindicated, consider passive immunization with tetanus immune globulin in a tetanus-prone wound. WATER CONTACT AND CLEANING 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. 26-28 Using soap and tap water to cleanse lacerations will not increase the infection rate. 29 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 infection. When delayed primary closure is anticipated, the dressing should remain undisturbed for 4 to 5 days until the patient is reevaluated by the physician. 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. 30 Reapplication of topical antibiotics for 3 to 5 days will decrease scab formation, thereby preventing wound edge separation. Patients with wounds closed with tissue adhesives may occasionally and briefly get the area wet, but should avoid bathing and swimming because prolonged moisture will loosen the adhesive bond and result in earlier sloughing of the adhesive. PAIN CONTROL 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.

wet, but should avoid bathing and swimming because prolonged moisture will loosen the adhesive bond and result in earlier sloughing of the adhesive. PAIN CONTROL 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 antiinflammatory 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. FOLLOW-UP Tell patients when and with whom to follow up for suture removal or wound examination. 30 Appropriate time to remove nonabsorbable sutures or staples varies by location (Table 47-3). Facial sutures are removed in 3 to 5 days to avoid formation of unsightly sinus tracts and hatch marks. 32 Sutures over the joints or on the hands should be left in place for 10 to 14 days, as they may be subject to increased tension dur ing movement. Debride any scab or crusting engulfing the sutures before suture removal, such as by gently applying gauze soaked with hydrogen per oxide. When removing sutures, grasp the suture at the knot with the forceps for removal (Figure 47-1). Avoid applying tension in a direction that would tend to cause dehiscence. Use scissors or a #12 blade to cut the sutures. Skin staples are removed with a 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, scrubbing the area, or exposing it to water TABLE 47-1 Postrepair Oral Antibiotic Prophylaxis Situation Primary Recommendation Alternative Recommendation Uncomplicated patient First-generation cephalosporin or antistaphylococcal penicillin Macrolide Clindamycin Grossly contaminated wounds and/or retained foreign body Amoxicillin-clavulanate or second-generation cephalosporin Clindamycin plus a fluoroquinolone Bite wounds Amoxicillin-clavulanate Clindamycin plus either a fluoroquinolone or trimethoprim-sulfamethoxazole Plantar puncture wounds Ciprofloxacin First-generation cephalosporin or antistaphylococcal penicillin Underlying systemic immunodeficiency (acquired immunodeficiency syndrome, chronic steroid use, poorly controlled diabetes mellitus) Amoxicillin-clavulanate or second-generation cephalosporin Clindamycin plus a fluoroquinolone Impaired local defenses (peripheral arterial disease, lymphedema) Amoxicillin-clavulanate Clindamycin or erythromycin TABLE 47-2 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 ≥3 doses Last dose within 5 y No No No No Last dose between 5–10 y No No Yes No Last dose >10 y Yes No Yes No Abbreviation: TIG = tetanus immune globulin. *Especially if wound care delayed (>6 h), deep (>1 cm), grossly contaminated, exposed to saliva or feces, stellate, ischemic or infected, avulsions, punctures, or crush injuries. †Tetanus toxoid: Tdap (tetanus, diphtheria, and pertussis) if adult and no prior record of administration or age >65 y; otherwise, tetanus-diphtheria toxoid if >7 y and diphtheria-tetanus toxoid if <7 y, preferably administered into the deltoid. ‡Tetanus immune globulin: adult dose, 250–500 IU administered into deltoid opposite the tetanusdiphtheria toxoid immunization site.

) if adult and no prior record of administration or age >65 y; otherwise, tetanus-diphtheria toxoid if >7 y and diphtheria-tetanus toxoid if <7 y, preferably administered into the deltoid. ‡Tetanus immune globulin: adult dose, 250–500 IU administered into deltoid opposite the tetanusdiphtheria toxoid immunization site. Tintinalli_Sec06_p0267-0328.indd 325 8/2/19 7:16 PM

) if adult and no prior record of administration or age >65 y; otherwise, tetanus-diphtheria toxoid if >7 y and diphtheria-tetanus toxoid if <7 y, preferably administered into the deltoid. ‡Tetanus immune globulin: adult dose, 250–500 IU administered into deltoid opposite the tetanusdiphtheria toxoid immunization site. Tintinalli_Sec06_p0267-0328.indd 325 8/2/19 7:16 PM 326 SECTION 6: Wound Management FIGURE 47-1. Suture removal. A. For simple interrupted percutaneous sutures, grasp the suture with the forceps at the knot, cut the suture with scissors on the side of the wound opposite the knot, and pull the knot across the wound. B. Alternatively, cut the suture with a curved #12 blade on the side of the wound opposite the knot (left) and pull the knot across the wound (right). C. For vertical mattress sutures, cut the suture on the side opposite the knot and pull the knot with forceps. D. For horizontal mattress sutures, cut the suture on the side opposite the knot and pull the knot with forceps. [A, C, and D reproduced with permission from Reichman EF (ed): Reichman’s Emergency Medical Procedures, 3rd ed. New York, NY: McGraw-Hill, Inc.; 2019, Figure 21.] FIGURE 47-2. Skin staple removal. A. Place the lower jaw of the staple remover under the horizontal portion of the staple. B. The upper jaw deforms the center of the staple and extracts the vertical legs from the skin. [Reproduced with permission from Reichman EF (ed): Reichman’s Emergency Medical Procedures,   3rd  ed.  New  York,  NY:  McGraw-Hill,  Inc.;  2019, Figure 116-28A&B.] TABLE 47-3 Suture and Staple Removal Recommendations Location Days Back 10–14 Buttocks 10–14 Chest 7–10 Delayed closure 8–12 Foot 10–14 Face 3–4 (child), 3–5 (adult) Hand 10–14 Legs 8–10 Neck 2–3 (child), 3–4 (adult) Overlying joints 10–14 Retention sutures 14–30 Scalp 10–14 Upper extremity 7–10 Source: Reproduced with permission from Reichman EF (ed): Reichman’s Emergency Medicine Procedures, 3rd ed. New York, NY: McGraw-Hill, Inc.; 2019, Table 114-5. 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 lacera tion 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 anti biotics without a reevaluation. 33 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. Tintinalli_Sec06_p0267-0328.indd 326 8/2/19 7:16 PM

ctions, do not prescribe anti biotics without a reevaluation. 33 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. Tintinalli_Sec06_p0267-0328.indd 326 8/2/19 7:16 PM CHAPTER 47: Postrepair Wound Care 327 LONG-TERM COSMETIC OUTCOME Educate patients about the expected outcome before wound closure. Reinforce 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. 34 For patients concerned about scar formation, scar-prevention therapies can be used after the initial phase of wound healing, typically after 2 weeks.35 Healing lacerations and abrasions should not be exposed to direct sunlight, because sun exposure can result in permanent hyperpigmentation. 36 Protect injured skin with a sun-blocking agent for 6 to 12 months after injury. REFERENCES The complete reference list is available online at www.TintinalliEM.com. Tintinalli_Sec06_p0267-0328.indd 327 8/2/19 7:16 PM Tintinalli_Sec06_p0267-0328.indd 328 8/2/19 7:16 PM