Acute Wound Care

Quick Reference

Critical Alerts

• Control hemorrhage first: Direct pressure for 5-10 minutes; tourniquet if life-threatening extremity bleeding
• Assess neurovascular status: Before anesthesia and after repair; document thoroughly
• Evaluate for underlying structures: Tendons, nerves, vessels, bone, joints - explore through full range of motion
• Time-dependent closure: Primary closure within 6-12 hours for clean wounds, up to 24 hours for facial wounds [1,2]
• Tetanus prophylaxis: Booster if > 5 years since last dose for tetanus-prone wounds, > 10 years for clean minor wounds [3]
• Selective antibiotic prophylaxis: Indicated for bites, deep punctures, contaminated wounds, delayed presentation (> 12 hours), immunocompromised patients [4,5]
• High-pressure irrigation essential: 50-100 mL per cm of wound length at 5-8 psi for contaminated wounds [6]

Wound Closure Decision Algorithm

Closure Methods Comparison

Emergency Initial Management

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Definition

Overview

Acute wound care encompasses the systematic evaluation, preparation, and closure of traumatic skin and soft tissue injuries. The primary objectives are: (1) control of hemorrhage, (2) prevention of infection through proper cleansing and selective antibiotic use, (3) restoration of tissue integrity and function, (4) optimization of healing conditions, and (5) minimization of scarring. [1] Evidence-based wound management requires careful assessment of mechanism, contamination level, time since injury, anatomic structures involved, and patient risk factors to guide closure method and timing. [2]

Classification Systems

By Mechanism of Injury

By Contamination Level

By Depth (Anatomic Layers Involved)

Epidemiology

• Incidence: Approximately 12 million emergency department visits annually in the United States for traumatic wounds; lacerations represent 8-10% of all ED presentations. [1]
• Age distribution: Bimodal peaks in children (5-14 years) due to play-related injuries and young adults (20-35 years) due to occupational and recreational trauma. [13]
• Anatomic distribution: Head and neck (35-40%, highest in children), upper extremities (30-35%), lower extremities (20-25%), trunk (5-10%). [1]
• Mechanisms: Falls (40%), sharp objects (25%), blunt trauma (20%), machinery/tools (10%), other (5%). [13]
• Infection rates: Overall 2-5% for properly managed wounds; increases to 10-20% for contaminated wounds, 15-30% for bites, up to 50% for wounds presenting > 24 hours. [2,4]

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Pathophysiology

Normal Wound Healing Cascade

Wound healing is a complex, overlapping sequence of cellular and molecular events divided into four phases. Understanding these phases is essential for optimizing management and recognizing healing impairment. [15]

Phase 1: Hemostasis (Immediate - Minutes to Hours)

Timing: Immediately upon injury

Key Events:

• Vascular injury triggers vasoconstriction (neurogenic and humoral)
• Platelet adhesion to exposed collagen via von Willebrand factor
• Platelet activation and degranulation release: ADP, thromboxane A2, serotonin
• Platelet aggregation forms temporary hemostatic plug
• Coagulation cascade activation (intrinsic and extrinsic pathways converge on Factor X)
• Fibrin mesh formation stabilizes platelet plug
• Provisional fibrin matrix serves as scaffold for cell migration

Clinical Significance: Anticoagulated patients have prolonged hemostasis phase; direct pressure remains effective but may require 10-15 minutes rather than 5 minutes. [9]

Phase 2: Inflammation (0-3 Days)

Timing: Begins within hours, peaks at 24-48 hours, transitions by day 3-4

Early Inflammation (0-24 hours):

• Vasodilation increases blood flow and vascular permeability
• Neutrophil chemotaxis (IL-8, complement C5a, LTB4) and extravasation
• Neutrophils phagocytose bacteria and debris
• Neutrophil apoptosis begins by 24 hours

Late Inflammation (24-72 hours):

• Macrophage recruitment (monocyte chemotactic protein-1, MCP-1)
• Macrophages phagocytose apoptotic neutrophils and debris
• Macrophages secrete growth factors: PDGF, TGF-β, VEGF, FGF
• Transition from inflammatory to proliferative phase

Clinical Significance:

• Normal inflammation presents with erythema, warmth, and swelling - do not confuse with infection
• Infection characterized by: purulence, lymphangitic streaking, fever, wound breakdown
• NSAIDs may theoretically impair healing but clinical significance unclear for acute wounds [15]

Phase 3: Proliferation (4-21 Days)

Timing: Day 4 through approximately day 21 (variable)

Key Events:

• Granulation tissue formation: Fibroblasts migrate into wound, deposit collagen III (immature)
• Angiogenesis: VEGF stimulates new capillary formation for oxygen/nutrient delivery
• Epithelialization: Keratinocytes migrate from wound edges (contact inhibition when edges meet)
• Contraction: Myofibroblasts reduce wound surface area (up to 40% reduction)

Collagen Synthesis:

• Fibroblasts produce primarily Type III collagen initially
• Requires vitamin C (cofactor for prolyl hydroxylase), adequate protein, oxygen
• Tensile strength increases rapidly during this phase

Clinical Significance:

• Wounds gain approximately 20% of final tensile strength by 3 weeks [15]
• Premature suture removal during this phase increases dehiscence risk
• Moist wound environment accelerates epithelialization by 50% [16]

Phase 4: Remodeling (21 Days - 1-2 Years)

Timing: Begins around day 21, continues for months to years

Key Events:

• Type III collagen (immature) replaced by Type I collagen (mature, stronger)
• Collagen cross-linking increases tensile strength
• Collagenase (MMP-1, MMP-8) remodels excessive collagen
• Scar tissue reorganizes along lines of tension
• Vascularity decreases (scar becomes paler)

Tensile Strength Recovery:

• 3 weeks: 20% of normal skin
• 6 weeks: 50% of normal skin
• 3 months: 80% of normal skin
• Maximum: 80-85% of original tensile strength (never 100%) [15]

Clinical Significance:

• Scars continue to remodel for 12-24 months (counsel patients on delayed final appearance)
• Hypertrophic scars result from excessive collagen deposition within wound boundaries
• Keloid scars extend beyond original wound boundaries (genetic predisposition)

Factors Impairing Wound Healing

Understanding healing impairment is critical for risk stratification and patient counseling. [17]

Systemic Factors

Diabetes Mellitus:

• Mechanisms: Hyperglycemia impairs neutrophil chemotaxis, phagocytosis, and bactericidal activity; advanced glycation end-products (AGEs) impair collagen cross-linking; microangiopathy reduces tissue perfusion and oxygen delivery; neuropathy reduces protective sensation. [18]
• Clinical Impact: Healing time increased 30-50%; infection risk doubled; dehiscence risk tripled in poorly controlled diabetes (HbA1c > 8%). [18]
• Management: Optimize glucose control perioperatively; consider delayed closure for contaminated wounds; lower threshold for antibiotics.

Malnutrition:

• Mechanisms: Protein deficiency impairs fibroblast proliferation and collagen synthesis; vitamin C deficiency impairs collagen hydroxylation (scurvy); zinc deficiency impairs epithelialization; vitamin A deficiency impairs epithelialization and immunity. [17]
• Clinical Impact: Serum albumin less than 3.0 g/dL associated with 3-fold increased dehiscence risk. [17]
• Management: Nutritional supplementation; consider delayed closure for severe malnutrition.

Corticosteroids and Immunosuppression:

• Mechanisms: Steroids suppress inflammatory phase (macrophage function, growth factor release), inhibit fibroblast proliferation and collagen synthesis, impair epithelialization, increase infection risk. [19]
• Clinical Impact: Chronic steroid use (> 10 mg prednisone equivalent daily) delays healing by 30-50%; increased infection risk 2-3 fold. [19]
• Management: Cannot discontinue acutely; meticulous wound care; lower threshold for delayed closure and antibiotics.

Smoking:

• Mechanisms: Nicotine causes vasoconstriction (reduced tissue perfusion); carbon monoxide reduces oxygen-carrying capacity; hydrogen cyanide inhibits cellular oxidative enzymes; impaired neutrophil function and collagen synthesis. [17]
• Clinical Impact: 2-3 fold increased infection and dehiscence risk; flap necrosis increased 6-fold. [17]
• Management: Smoking cessation counseling; even 2-4 weeks abstinence improves outcomes.

Chronic Diseases:

• Chronic kidney disease: Uremia impairs neutrophil and fibroblast function
• Liver disease: Coagulopathy, hypoalbuminemia, immunosuppression
• Peripheral vascular disease: Tissue hypoxia, impaired healing (especially lower extremities)
• Connective tissue disorders: Abnormal collagen (Ehlers-Danlos syndrome)

Local Factors

Infection:

• Bacterial load > 10^5 organisms per gram tissue impairs healing [2]
• Prolongs inflammatory phase, increases tissue destruction
• Beta-hemolytic streptococci particularly detrimental even at lower counts

Tissue Hypoxia:

• Adequate oxygen tension (PaO2 > 40 mmHg in tissue) required for collagen synthesis
• Causes: Hypotension, anemia, vasoconstriction, vascular disease
• Hyperbaric oxygen may benefit select chronic wounds but not routine acute wounds

Foreign Bodies:

• Any foreign material reduces infection threshold 10,000-fold [2]
• Suture material itself is foreign body (absorbable sutures reduce chronic inflammation)
• Soil, wood, clothing fragments must be removed

Wound Tension:

• Excessive tension impairs perfusion, increases dehiscence risk
• Undermining reduces closure tension
• Layered closure distributes tension across tissue planes

Hematoma/Seroma:

• Collection creates dead space, separates tissue planes
• Serves as culture medium for bacteria
• Management: Avoid with meticulous hemostasis, consider drain for large dead space

Tissue Trauma During Repair:

• Excessive manipulation, crushing with forceps, electrocautery char
• "Handle tissue like it's your own retina" surgical adage
• Use atraumatic technique, fine instruments, minimal necessary cautery

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Clinical Presentation

Initial Assessment

A systematic, reproducible wound assessment protocol reduces missed injuries and improves outcomes. [12]

History Taking

AMPLE History (adapted for wound care):

• Allergies: Anesthetics (amide vs ester), antibiotics, adhesives, latex
• Medications: Anticoagulants (warfarin, DOACs, antiplatelets), immunosuppressants, steroids
• Past medical history: Diabetes, vascular disease, immunocompromise, bleeding disorders
• Last tetanus: Date of last tetanus vaccine, total number of doses
• Events: Mechanism, time of injury, environment (contaminated?)

Mechanism-Specific Questions:

Timing Questions:

• Time since injury: Critical for closure decision (see closure algorithm)
• Pre-hospital care: Hemostasis methods, tourniquets applied (note time), wound cleaning attempted
• Tetanus vaccination history: Last booster date, primary series completed

Patient Factors:

• Hand dominance: For upper extremity wounds
• Occupation: Manual laborer, musician (functional requirements)
• Cosmetic concerns: Keloid history, occupation requiring appearance (actor, model)

Physical Examination

Systematic Inspection:

1. Hemostasis status: Active bleeding, oozing, controlled
2. Wound dimensions: Length (cm), width, depth (superficial, partial, full-thickness, deep)
3. Wound edges: Smooth vs irregular, viable vs devitalized, degree of gaping
4. Contamination: Visible debris, soil, organic material, rust
5. Surrounding skin: Erythema (normal in first 24h vs spreading), induration, ecchymosis

Structured Neurovascular Examination:

Upper Extremity:

Vascular:

• Pulses: Radial, ulnar, digital (use Doppler if non-palpable)
• Capillary refill: less than 2 seconds normal
• Allen test: For radial/ulnar artery patency if wrist laceration
• Expanding hematoma suggests active arterial bleeding

Lower Extremity:

Vascular: Femoral, popliteal, dorsalis pedis, posterior tibial pulses; ankle-brachial index if vascular injury suspected

Tendon Examination:

• Critical principle: Examine through full range of motion (tendon position changes with joint position; partial lacerations may be missed) [12]
• Hand tendons: Test each finger individually in isolation
  • "Flexor digitorum profundus (FDP): DIP flexion with PIP held extended"
  • "Flexor digitorum superficialis (FDS): PIP flexion with adjacent fingers held extended"
  • "Extensor digitorum communis: MCP extension with wrist supported"
• Achilles tendon: Thompson test (calf squeeze should produce plantarflexion)
• Patellar tendon: Ability to extend knee against resistance, straight leg raise

Joint Involvement:

• Wounds over joints: Rule out penetration (arthrocentesis if suspected)
• Joint effusion, limited range of motion
• "Fight bite" (human bite over MCP joint) has 25-50% joint capsule penetration rate [20]

Foreign Body Assessment:

• Visible foreign material
• High-risk mechanisms: Glass, gravel, wood splinters, clothing fibers
• Palpation (sterile glove): Crepitus suggests glass, deep exploration (use anesthesia)
• Document: "No foreign body visualized" (cannot definitively exclude without imaging)

Wound Exploration:

• Adequate anesthesia required for thorough, comfortable examination
• Visualization of wound base and full depth
• Direct visualization of tendons, nerves, vessels if deep
• Exploration through full range of motion (especially hands)

Severity Stratification

Low Risk (Uncomplicated outpatient management):

• Clean or clean-contaminated wound
• less than 12 hours old (facial less than 24 hours)
• No tendon, nerve, or vascular injury
• No joint involvement
• Superficial to full-thickness (not deep structures)
• Patient immunocompetent
• Good perfusion to area

Moderate Risk (May require specialty consultation):

• Contaminated wound
• 12-24 hours old
• Questionable tendon integrity
• Superficial nerve injury (sensory only)
• Wound over joint without penetration
• Diabetic patient
• Peripheral vascular disease

High Risk (Specialty consultation required):

• Heavily contaminated or infected

• 24 hours old

• Tendon laceration (motor deficit)
• Motor nerve injury
• Vascular injury
• Joint penetration
• Open fracture
• Compartment syndrome suspected
• Severe immunocompromise
• Bite wounds to hand
• High-pressure injection injury

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Red Flags

Life-Threatening Complications

Limb-Threatening Injuries

Infection Risk Factors Requiring Heightened Vigilance

Patient Factors:

• Diabetes (especially HbA1c > 8%)
• Chronic steroid use (> 10 mg prednisone equivalent daily)
• Immunosuppression (chemotherapy, biologics, HIV with CD4 less than 200)
• Chronic kidney disease (especially dialysis-dependent)
• Peripheral vascular disease (especially lower extremities)
• Cirrhosis (Child-Pugh B or C)
• Age > 65 years (relative risk 1.5-2x) [4]

Wound Factors:

• Bite wounds (human 30%, cat 20-50%, dog 15%) [20]
• Contaminated wounds (soil, feces, organic material)
• Crush injuries (devitalized tissue)
• Puncture wounds (especially through shoes - Pseudomonas risk)
• Wounds > 12 hours old (extremities) or > 24 hours (face)
• Wound location: Hand, foot, perineum (higher bacterial load)
• Presence of foreign body
• Inadequate initial irrigation

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Differential Diagnosis

Exclusion of Associated Injuries

The wound may be obvious, but associated injuries can be missed without systematic evaluation. [12]

Wound Mimics (Non-Traumatic Etiologies to Consider)

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Diagnostic Approach

Imaging

Radiography (X-Ray):

Indications:

• Suspected fracture (mechanism, tenderness, deformity)
• Radiopaque foreign body (glass > 2mm, metal, gravel, some wood)
• Wound over joint (rule out penetration, fracture)
• Bite wounds over bones/joints
• Puncture wounds (especially plantar foot)

Technique:

• Minimum 2 views (AP and lateral), 3 views for complex areas
• Include joint above and below for extremity injuries
• Soft tissue technique (underpenetrated) may better visualize glass, air
• Mark wound location with radiopaque marker if foreign body suspected

Findings:

• Fracture: Line of discontinuity, displacement, rotation
• Foreign body: Radiopaque material (sensitivity: 100% metal, 60-90% glass > 2mm, poor for wood/plastic)
• Air in soft tissues: Subcutaneous emphysema (gas-producing organism vs trauma)
• Joint effusion: Fat-fluid level (lipohemarthrosis) indicates intra-articular fracture
• Bone destruction: Osteomyelitis (chronic wounds)

Ultrasound:

Advantages over X-ray:

• Superior for radiolucent foreign bodies (wood, plastic, thorns)
• Real-time imaging allows guided foreign body removal
• No radiation exposure
• Can assess tendon integrity

Indications:

• Suspected foreign body with negative X-ray
• Assess tendon integrity (partial vs complete laceration)
• Guide foreign body removal
• Abscess evaluation (depth, size, location)

Technique:

• High-frequency linear probe (7-15 MHz)
• Compare to contralateral side
• Scan in two planes
• Dynamic scanning with range of motion for tendons

Findings:

• Foreign body: Hyperechoic focus with posterior shadowing or reverberation artifact
• Tendon laceration: Discontinuity of tendon fibers, gap with movement
• Abscess: Hypoechoic fluid collection

Computed Tomography:

• Reserved for complex wounds, suspected deep foreign bodies not seen on X-ray/ultrasound
• High sensitivity for foreign bodies
• Delineates anatomic structures for operative planning

Laboratory Testing

Not routinely indicated for simple traumatic wounds

Selective Laboratory Testing:

Wound Exploration

Critical Procedural Points:

1. Adequate anesthesia: Patient must be comfortable for thorough examination
2. Hemostasis: Temporary tourniquet (BP cuff inflated above systolic) for extremities allows visualization
3. Good lighting: Headlamp, surgical lighting
4. Through full range of motion: Especially hands - tendon position changes [12]
5. Systematic approach: Base to apex, visualize all structures
6. Document findings: "Wound explored; no tendon, nerve, or vascular injury visualized; no foreign body seen"

Red Flags During Exploration:

• Exposed bone or periosteum: May indicate open fracture
• Joint capsule visualization: Intra-articular extension
• Visible tendon that doesn't move with muscle contraction: Complete laceration
• Pulsatile bleeding: Arterial injury
• White, cord-like structure: Likely nerve (do not probe)

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Treatment

General Principles

The "Six Cs" of wound management:

1. Control bleeding (hemostasis)
2. Clean the wound (irrigation and cleansing)
3. Cut away devitalized tissue (debridement)
4. Close appropriately (primary, delayed, or secondary intention)
5. Cover with suitable dressing
6. Consider adjuncts (antibiotics, tetanus)

Hemostasis

Step-Wise Approach:

First-line: Direct Pressure:

• Apply firm, continuous pressure for 5-10 minutes (time it - do not "peek") [9]
• Elevate extremity above heart level
• Most wounds (95%) achieve hemostasis with pressure alone [9]

Second-line: Pressure Dressing:

• Gauze pads with circumferential wrap
• Elastic bandage provides continuous pressure
• Effective for ongoing oozing after direct pressure

Third-line: Tourniquet (life-threatening extremity hemorrhage):

• Commercial tourniquet device (CAT, SOFTT) preferred over improvised
• Place proximal to wound (upper arm or thigh)
• Document exact time of application
• Acceptable ischemia time: Up to 2 hours relatively safe; up to 4 hours in extreme circumstances
• Do not release until definitive hemostasis achieved (OR or vascular surgery available)

Adjuncts:

• Topical hemostatic agents: Thrombin-gelatin matrix (FloSeal), oxidized cellulose (Surgicel) for persistent oozing
• Electrocautery: For isolated bleeding vessels during wound exploration (use sparingly to minimize tissue damage)
• Ligation: Suture ligation of visible arterial bleeders (4-0 or 5-0 absorbable)
• Epinephrine: Lidocaine with epinephrine provides vasoconstriction (previously considered contraindicated in fingers/toes but now accepted as safe) [22]

Anesthesia

Local Infiltration Technique:

Agent Selection:

Pain Reduction Strategies:

1. Buffer anesthetic: 1:10 ratio of sodium bicarbonate 8.4% to lidocaine reduces injection pain by 50% [10]
   • Add 1 mL bicarbonate to 10 mL lidocaine
   • Must use within 30 minutes (precipitates over time)
2. Warm anesthetic: Warming to body temperature reduces pain
3. Inject through wound edges rather than intact skin (enters through already disrupted tissue barrier)
4. Slow injection: Rapid injection stretches tissues and causes pain
5. Small-gauge needle: 27-30 gauge
6. Distraction techniques: Especially in children

Topical Anesthesia:

• LET gel (4% lidocaine, 0.1% epinephrine, 0.5% tetracaine): Apply to wound for 20-30 minutes; effective for facial/scalp lacerations, especially pediatric
• EMLA cream (lidocaine-prilocaine): Intact skin only; apply 60 minutes before (limited ED utility)

Regional Nerve Blocks:

Digital Block (fingers/toes):

• Indications: Fingertip/toe lacerations, nail bed repairs
• Technique: Inject at base of digit, both sides (dorsal approach or volar approach)
• Volume: 1-2 mL each side
• Do not use epinephrine-containing solutions for nerve blocks (risk of ischemia in end-arterial supply)

Other Useful Blocks:

• Infraorbital block: Upper lip, lower eyelid, lateral nose
• Mental block: Lower lip, chin
• Supraorbital/supratrochlear: Forehead
• Radial/ulnar/median nerve blocks: Hand/wrist

Irrigation and Cleansing

High-volume, appropriate-pressure irrigation is the single most important intervention to prevent infection. [6]

Solution Selection:

Evidence-Based Recommendations:

• Tap water is equivalent to sterile saline for wound irrigation (multiple systematic reviews show no difference in infection rates) [11]
• Normal saline (0.9% NaCl): Traditional, isotonic, readily available
• Avoid: Hydrogen peroxide, povidone-iodine, chlorhexidine in wound bed (cytotoxic to healing tissues; acceptable for intact skin prep only) [6]

Irrigation Volume:

• Minimum: 50-100 mL per cm of wound length [6]
• Contaminated wounds: 200+ mL per cm
• Example: 5 cm laceration requires minimum 250-500 mL irrigation

Irrigation Pressure:

• Optimal: 5-8 psi (pounds per square inch) [6]
• Achieves mechanical removal of bacteria and debris without tissue damage
• Too low (less than 5 psi): Ineffective bacteria removal
• Too high (> 15 psi): Tissue damage, bacteria driven deeper

Achieving 5-8 psi:

Technique:

1. Don personal protective equipment (face shield, gown, gloves)
2. Position patient to allow runoff into basin or absorbent pads
3. Fill 35-60 mL syringe with irrigation solution
4. Attach 19-gauge needle or splash guard
5. Hold syringe 2-3 inches from wound
6. Irrigate with steady pressure, sweeping across wound
7. Repeat until entire volume delivered and wound debris-free

Scrubbing:

• For abraded/contaminated wounds with embedded debris
• Use soft surgical brush or gauze with mild soap
• Scrub gently to avoid further tissue damage
• Follow with copious irrigation

Debridement

Removal of devitalized tissue and foreign material is essential for infection prevention and optimal healing. [2]

Indications:

• Devitalized, non-viable tissue (pale, non-bleeding)
• Heavily contaminated or embedded foreign material
• Severely contused wound edges
• Tissue that will not survive (questionable if will be viable - allow 24-48h and reassess)

Technique:

• Sharp debridement with scalpel or scissors
• Trim minimally (conservative debridement - tissue is precious)
• Debride back to healthy, bleeding tissue
• Create clean wound edges (may convert irregular laceration to "surgical" wound)

Special Considerations:

• Facial wounds: Maximal tissue conservation (excellent blood supply allows marginal tissue to survive)
• Fingertips: Conservative - even apparently devitalized tissue may survive
• Questionable viability: Delay and reassess in 24-48 hours rather than excessive immediate debridement

Wound Closure

Primary Closure:

Indications:

• Clean or clean-contaminated wounds
• Time since injury: less than 6-12 hours for extremities/trunk, less than 24 hours for face/scalp (due to rich vascular supply) [1,2]
• Adequate tissue viability
• Low infection risk

Contraindications to Primary Closure:

• Infected wounds (purulence, cellulitis)
• Heavily contaminated wounds not adequately cleaned
• Significant devitalized tissue
• High-risk wounds: Bites (except facial), crush injuries, deep punctures
• Delayed presentation (> 12 hours for extremities, > 24 hours for face)
• Patient unable to follow up for wound check

Closure Method Selection:

Sutures:

• Indications: Most lacerations, wounds under tension, need for precise approximation, deep wounds
• Advantages: Strongest closure, most versatile, best for uneven wound edges
• Disadvantages: Painful placement, requires removal, slower, higher infection risk than alternatives (foreign body effect)

Suture Material Selection:

Suture Techniques:

• Simple interrupted: Most common, versatile, allows adjustment of each stitch
• Vertical mattress: Everts wound edges, good for areas where inversion likely (backs, extremities)
• Horizontal mattress: Reduces tension, good for fragile skin (elderly)
• Running (continuous): Faster, good for long linear lacerations, less precise
• Subcuticular: Absorbable or removable running suture below epidermis, excellent cosmesis
• Deep dermal: Absorbable buried sutures to close dead space, reduce tension on skin

Technical Principles:

• Needle entry/exit equidistant from wound edge (typically 2-3mm for face, 4-5mm for extremities)
• Stitch spacing approximately equal to distance from wound edge
• Tie just tight enough to approximate edges (not strangulate)
• Evert wound edges slightly (flatten during healing)

Staples:

• Indications: Scalp, trunk, proximal extremities; linear lacerations; hair-bearing areas [7]
• Advantages: Fastest closure method (50% time reduction vs sutures), cost-effective, equivalent outcomes for appropriate wounds [7]
• Contraindications: Face (cosmesis), hands/feet (painful removal), over joints (movement)
• Technique: Evert edges with forceps, apply staple perpendicular to wound, ensure both sides of staple in skin

Tissue Adhesive (2-octyl cyanoacrylate, e.g., Dermabond):

• Indications: Superficial (less than 5mm deep), clean, low-tension lacerations; pediatric facial lacerations [8]
• Advantages: Painless application, no removal needed, faster than sutures, equivalent cosmetic outcomes [8], waterproof immediately
• Contraindications: High-tension wounds, deep wounds, over joints, hair-bearing areas (adhesive glues hair), mucosal surfaces, hands (frequent washing), infected/contaminated wounds
• Technique:
  1. Ensure wound dry (adhesive will not bond to wet surface)
  2. Approximate wound edges with forceps or fingers
  3. Apply thin layer of adhesive along wound (do not get inside wound - toxic to tissues)
  4. Hold edges together 30 seconds
  5. Apply 2-3 layers (wait 30 seconds between layers)
  6. Adhesive sloughs off spontaneously in 7-10 days

Steri-Strips (Adhesive Tape):

• Indications: Very superficial lacerations, minimal tension, wound reinforcement after suture removal, surgical incision reinforcement
• Advantages: Non-invasive, painless, no removal needed (fall off in 7-10 days)
• Contraindications: Active bleeding (won't stick), high tension, irregular wound edges
• Technique:
  1. Ensure wound edges dry (swab with alcohol, allow to dry, or apply tincture of benzoin for better adhesion)
  2. Apply strips perpendicular to wound, starting at midpoint
  3. Space 2-3mm apart
  4. May reinforce with strips parallel to wound

Delayed Primary Closure:

• Indications: Contaminated wounds after thorough irrigation/debridement, wounds 12-24+ hours old, high infection risk wounds, patient preference for observation
• Timing: 3-5 days after injury (after inflammatory phase but before excessive granulation)
• Technique:
  1. Initial management: Irrigate, debride, pack wound open with saline-moistened gauze
  2. Wound checks: Daily or every other day
  3. Closure: When wound clean, no signs of infection (typically day 3-5)
  4. Close with sutures (tissue adhesive not suitable for delayed closure)

Secondary Intention (Healing by Granulation):

• Indications: Infected wounds, abscesses (after I&D), heavily contaminated wounds that cannot be adequately cleaned, significant tissue loss precluding primary closure, patient preference
• Management:
  1. Keep wound moist (saline-moistened gauze or hydrogel)
  2. Daily dressing changes initially
  3. Transition to less frequent changes as granulation tissue forms
  4. May consider delayed closure or skin graft if large defect

Layered Closure Principles

For deep wounds (into subcutaneous fat or deeper), layered closure is essential to:

1. Eliminate dead space (reduce hematoma/seroma risk)
2. Reduce tension on skin layer (improve cosmesis)
3. Provide strength during healing

Technique:

1. Deep layer: Absorbable sutures (3-0 or 4-0 Vicryl) to approximate subcutaneous tissue and dermis
   • Bury knots (invert so knot is deep to surface)
   • Place to eliminate dead space
   • Do not place too many (each suture is foreign body)
2. Skin layer: Non-absorbable sutures or tissue adhesive
   • Should approximate with minimal tension if deep layer placed properly
   • May use running subcuticular absorbable suture instead of skin sutures (excellent cosmesis, no removal needed)

Tetanus Prophylaxis

Tetanus immunization status must be assessed for all wounds. [3]

Tetanus-Prone Wounds:

• 6 hours old

• 1 cm deep

• Crush, puncture, avulsion mechanism
• Contaminated with soil, feces, saliva
• Devitalized tissue
• Infected

Decision Algorithm:

Tdap vs Td:

• Tdap (tetanus, diphtheria, acellular pertussis): Preferred if patient has not received Tdap as adult (provides pertussis protection)
• Td (tetanus, diphtheria): Acceptable if Tdap previously received or unavailable

Special Populations:

• Pregnancy: Tdap recommended in each pregnancy (27-36 weeks optimal, but can give at time of wound if indicated)
• Immunocompromised: Standard schedule, consider TIG more liberally
• HIV: Standard schedule (antibody response may be blunted if CD4 less than 200)

Antibiotic Prophylaxis

Prophylactic antibiotics are indicated for select high-risk wounds, not routine simple lacerations. [4,5]

Evidence-Based Indications:

NOT Indicated (no evidence of benefit):

• Simple, clean lacerations [5]
• Facial lacerations (unless bite or through-and-through oral)
• Scalp lacerations
• Sutured lacerations in healthy patients without above indications

Antibiotic Selection:

First-line:

• Amoxicillin-clavulanate 875/125 mg PO BID: Broad coverage including Pasteurella (animal bites), oral anaerobes, Streptococcus, Staphylococcus

Penicillin-Allergic:

• Non-severe allergy (rash): Cefuroxime 500 mg PO BID or cephalexin 500 mg PO QID
• Severe allergy (anaphylaxis):
  • "Bites: Doxycycline 100 mg PO BID + metronidazole 500 mg PO TID"
  • "Non-bite: Trimethoprim-sulfamethoxazole DS PO BID or clindamycin 300-450 mg PO TID"

Special Situations:

• Puncture through shoe (Pseudomonas risk): Ciprofloxacin 500 mg PO BID
• Aquatic exposure (freshwater/saltwater): Doxycycline 100 mg PO BID (covers Aeromonas, Vibrio)
• Immunocompromised: Consider broader spectrum (e.g., fluoroquinolone + coverage for MRSA if high local prevalence)

Duration:

• Prophylaxis: 3-5 days
• Established infection: 7-10 days or longer based on clinical response

Wound Dressing Selection

The ideal dressing maintains moist wound environment (accelerates epithelialization by 50% vs dry), absorbs excess exudate, protects from contamination, and is comfortable. [16]

Evidence-Based Principles:

• Moist wound healing is superior to dry (faster epithelialization, less pain, better cosmesis) [16]
• Simple non-adherent dressing adequate for most sutured wounds [24]
• No single dressing proven superior for acute traumatic wounds [24]

Dressing Selection by Wound Type:

Specific Dressing Types:

Non-adherent (Telfa, Adaptic):

• Petrolatum or silicone-impregnated gauze
• Does not stick to wound, reduces pain with dressing changes
• First-line for most sutured/stapled wounds

Hydrocolloid (DuoDERM):

• Absorbs exudate, maintains moist environment
• Can leave in place 3-5 days
• Good for abrasions, superficial partial-thickness wounds
• Forms gel that may appear purulent (normal, not infection)

Hydrogel:

• Donates moisture (good for dry wounds)
• Promotes autolytic debridement
• Good for healing by secondary intention

Foam:

• Absorbs moderate-high exudate
• Maintains moist environment
• Good for granulating wounds with moderate drainage

Saline-moistened gauze:

• Wet-to-moist (NOT wet-to-dry which damages granulation tissue)
• Inexpensive, readily available
• Good for infected wounds, wounds being observed before closure

Antibiotic Ointment:

• Minimal evidence of benefit for infection prevention in sutured wounds [24]
• May improve patient comfort (keeps wound moist)
• Acceptable: Bacitracin (low allergy rate), white petrolatum (non-antibiotic alternative)
• Avoid: Neomycin (high allergy rate 10-15%)
• Not necessary if patient can keep wound clean with soap and water

First Dressing (Applied in ED):

• Non-adherent layer against wound
• Absorbent gauze layer (4x4s)
• Secured with tape or gauze wrap (do not circumferentially wrap extremities too tightly - can cause tourniquet effect with swelling)
• Splint if over joint or high-risk for disruption

Special Wound Considerations

Facial Wounds:

• Cosmesis critical: Use finest sutures (6-0 or 5-0), precise approximation, evert edges
• Remove early: 5-7 days (excellent blood supply allows early removal)
• Consider plastic surgery: Full-thickness lip/eyelid, vermillion border, complex lacerations
• Tissue adhesive excellent for pediatric facial lacerations (equivalent cosmesis, less traumatic) [8]

Scalp Wounds:

• Excellent blood supply: May bleed profusely (direct pressure, hemostatic sutures, epinephrine)
• Hair apposition technique: For very superficial lacerations in long hair (twist hair on either side together, apply tissue adhesive) - avoid unless very superficial
• Staples vs sutures: Staples faster, equivalent outcomes, easier removal [7]
• Palpate for depressed skull fracture

Hand Wounds:

• High-risk for infection: Tendon sheaths, joint spaces, deep spaces
• Mandatory exploration through full ROM [12]
• "Fight bite" (over MCP joint): Assume joint penetration, often requires operative washout
• Refer tendon/nerve injuries to hand surgery
• Splint in position of function (wrist 20° extension, MCP 70° flexion, IP extended)

Plantar Foot Wounds (especially puncture):

• Pseudomonas risk if through shoe (bacteria from sole driven into foot)
• Wound exploration often unrevealing (deep tract)
• Do not close punctures
• Consider antibiotics (ciprofloxacin if through shoe)
• X-ray to rule out foreign body
• Close follow-up (osteomyelitis risk, usually delayed presentation at 2-4 weeks)

Wounds Over Joints:

• Rule out penetration: Arthrocentesis if high suspicion (WBC > 50,000 suggests septic joint)
• Delayed suture removal: 14 days (increased tension with movement)
• Splint to minimize movement during healing

Lip Lacerations:

• Vermillion border: Must align precisely (1-2mm mismatch is cosmetically apparent)
• Through-and-through: Close in layers (oral mucosa with absorbable, muscle, skin)
• Oral mucosa: Use absorbable sutures (chromic gut or Vicryl)

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Disposition

Discharge Criteria

Safe for Discharge:

• Hemostasis achieved
• Wound adequately irrigated, debrided, and closed (or left open by design)
• No missed tendon, nerve, or vascular injury
• Tetanus status addressed
• Pain controlled with oral analgesics
• Patient understands wound care instructions
• Follow-up arranged (suture removal, wound check)
• Patient has reliable transportation and support
• No signs of compartment syndrome (if applicable)

Discharge Instructions (provide written and verbal):

1. Wound care: Keep clean and dry for first 24 hours, then gentle washing with soap and water daily
2. Dressing changes: Frequency based on wound type (see dressing section)
3. Activity restrictions: Avoid strenuous activity, heavy lifting, or activities that stress wound
4. Suture/staple removal: Date and location (PCP, ED, wound clinic)
5. Signs of infection: Increasing redness/warmth/swelling, red streaks, purulent drainage, fever > 38°C (100.4°F)
6. When to return: Signs of infection, wound opening, numbness/weakness, uncontrolled pain

Prescriptions:

• Analgesics: Acetaminophen 650-1000 mg q6h PRN; ibuprofen 400-600 mg q6h PRN; tramadol 50 mg q6h PRN for moderate pain; oxycodone 5 mg q4-6h PRN for severe pain (3-day supply maximum)
• Antibiotics: Only if indicated (see antibiotic prophylaxis section)
• Tetanus vaccine: If not available in ED, prescription/referral for administration within 72 hours

Specialty Referral

Immediate/Urgent Referral (same day or next day):

Outpatient Referral (within 1-2 weeks):

Follow-Up Plan

Wound Check (24-48 hours):

• Indications: Bite wounds, contaminated wounds, high-risk patients (diabetes, immunocompromised), wounds with borderline closure decision
• Assess: Signs of infection, wound edge approximation, neurovascular status
• Action: Remove sutures and allow delayed closure if infection developing; initiate antibiotics if indicated

Suture/Staple Removal:

Early Removal + Reinforcement:

• Remove alternating sutures at earlier timepoint, apply Steri-strips
• Remove remaining sutures 3-5 days later
• Reduces railroad tracking (epithelialization along suture tracts)

Long-Term Follow-Up:

• Scar maturation counseling at 2-4 weeks (scars continue to improve for 12-24 months)
• Silicone gel sheeting or pressure garment for hypertrophic scar prevention (especially keloid-prone patients)
• Sun protection (UV exposure darkens scars)

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Complications

Early Complications (0-7 Days)

Wound Infection:

• Incidence: 2-5% for properly managed simple lacerations; 10-50% for bites, contaminated, delayed wounds [2,4]
• Timing: Typically 24-72 hours (may be delayed up to 7-10 days)
• Clinical features: Increasing erythema (> 2cm from wound edge), warmth, swelling, purulent drainage, lymphangitic streaks, fever
• Management:
  • Remove sutures/staples to allow drainage
  • Wound culture (Gram stain, aerobic and anaerobic cultures)
  • "Empiric antibiotics: Cephalexin 500 mg PO QID or amoxicillin-clavulanate 875/125 mg PO BID (adjust based on culture)"
  • Warm compresses, elevation
  • Daily wound checks until improving
  • "Admission for IV antibiotics if: Systemic toxicity, immunocompromised, failed outpatient therapy, deep space infection"

Hematoma/Seroma:

• Prevention: Meticulous hemostasis, layered closure to eliminate dead space, pressure dressing
• Management: Small hematomas resorb spontaneously; large/expanding hematomas may require evacuation (remove sutures, express hematoma, re-close or pack)

Wound Dehiscence:

• Risk factors: Infection, excessive tension, premature suture removal, poor technique, patient non-compliance (excessive activity)
• Management: If early (less than 5 days) and no infection, may re-close; if later or infected, allow secondary intention healing

Allergic Reaction:

• Contact dermatitis: Tape, antibiotic ointment (especially neomycin), tissue adhesive (rare)
• Anesthetic allergy: True allergy rare; most reactions vasovagal or epinephrine effect (palpitations)
• Management: Discontinue offending agent, topical corticosteroid for contact dermatitis

Intermediate Complications (1-4 Weeks)

Suture Abscess (Spitting Suture):

• Body rejects buried suture (usually non-absorbable or slow-absorbing)
• Presents as small pustule along suture line
• Management: Remove offending suture

Hypertrophic Scar (Early Formation):

• Excessive collagen deposition within wound boundaries
• Raised, red, pruritic
• Management: Silicone gel sheeting, intralesional corticosteroid (triamcinolone 10-40 mg/mL)

Late Complications (> 1 Month)

Keloid Scar:

• Excessive collagen extending beyond wound boundaries
• Genetic predisposition (more common in darker skin types)
• Management: Intralesional corticosteroid, silicone gel, pressure garments; may require excision with adjuvant therapy (radiation, imiquimod)

Unsatisfactory Scarring:

• Wide scar, depressed scar, hyperpigmented scar
• Prevention: Evert edges, minimize tension, sun protection
• Management: Scar revision (not before 12 months - allow full maturation)

Neuropathic Pain:

• Neuroma formation from nerve injury
• Burning, shooting pain, allodynia
• Management: Gabapentin, topical lidocaine, nerve block; neuroma excision if refractory

Functional Deficit:

• Missed tendon/nerve injury, scarring with contracture
• Management: Surgical exploration and repair, therapy

---

Special Populations

Pediatric Patients

Unique Considerations:

• Procedural anxiety: Topical anesthesia (LET gel), distraction techniques, child life specialist
• Sedation: May be required for extensive or complex repairs (consider intranasal fentanyl, oral midazolam, ketamine)
• Tissue adhesive preferred when appropriate (less traumatic, equivalent cosmesis) [8]
• Parent presence: Generally helpful for calming child
• Child abuse screening: Injuries inconsistent with developmental stage or history

Elderly Patients

Unique Considerations:

• Fragile skin: Tears easily, poor elasticity
• Impaired healing: Due to age-related changes, comorbidities, medications (steroids)
• Closure method: Steri-strips or tissue adhesive often preferred over sutures (less trauma to fragile skin)
• Consider delayed closure more liberally
• Polypharmacy: Anticoagulants (hemostasis challenging), steroids (impaired healing)

Anticoagulated Patients

Management Approach:

• Hemostasis challenging but achievable: Direct pressure for 10-15 minutes (vs 5 minutes for non-anticoagulated)
• DO NOT reverse anticoagulation for simple wounds (risk of reversal > benefit)
• Consider reversal for: Expanding hematoma, compartment syndrome, severe bleeding not controlled with pressure
• Technique: Meticulous hemostasis, consider layered closure to reduce dead space/hematoma risk, pressure dressing
• Anticoagulation-specific:
  • "Warfarin: INR 2-3 generally OK, > 4-5 consider vitamin K 1-2.5 mg PO (onset 12-24h)"
  • "DOACs (dabigatran, rivaroxaban, apixaban): No routine reversal for simple wounds"
  • "Antiplatelet agents: Continue (bleeding risk manageable with pressure)"

Diabetic Patients

Management Approach:

• Optimize glucose perioperatively if possible
• Lower threshold for antibiotics (impaired neutrophil function) [18]
• Consider delayed closure for contaminated wounds
• Meticulous follow-up: Wounds heal slower, higher infection risk
• Peripheral neuropathy: Patients may not feel pain (missed injuries, non-compliance with offloading)
• Peripheral vascular disease: Especially lower extremities - assess perfusion

Immunocompromised Patients

Causes: HIV, chemotherapy, chronic steroids, biologic agents (TNF-alpha inhibitors), organ transplant

Management Approach:

• Lower threshold for antibiotics
• Consider delayed closure for contaminated wounds
• Close follow-up: Infection may be subtle (normal inflammatory response blunted)
• Tetanus: Standard schedule but may have blunted antibody response (consider TIG more liberally)

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Patient Education

Wound Care Instructions

First 24 Hours:

• Keep wound clean and dry
• Leave initial dressing in place unless bleeding or saturated
• Elevate injured area above heart level (if extremity) to reduce swelling
• Ice packs for 20 minutes each hour while awake (first 24-48 hours) to reduce pain and swelling
• Avoid getting wound wet (no shower/bath if possible)

After 24 Hours:

• May shower (brief, gently pat dry afterward); avoid soaking (no bathing, swimming, hot tubs)
• Gently wash wound daily with mild soap and water
• Pat dry with clean towel
• May apply thin layer of white petrolatum or antibiotic ointment (optional)
• Apply clean dressing

Activity Restrictions:

• Avoid strenuous activity, heavy lifting (> 10 lbs), or activities that stress wound for 2-3 weeks (varies by location)
• Do not stretch wound excessively
• Splint if over joint (duration based on location)

Suture/Staple Care:

• Keep dry for first 24-48 hours
• Do not pick at or pull on sutures
• Return for removal on scheduled date (premature removal increases dehiscence risk)

Scar Minimization:

• After sutures removed: Massage scar gently with moisturizer (breaks up collagen, improves pliability)
• Sun protection essential for 12 months (UV darkens scars): Sunscreen SPF 30+, cover with clothing
• Silicone gel sheeting may reduce hypertrophic scar formation (especially if keloid-prone)

Warning Signs to Return Immediately

Signs of Infection:

• Increasing redness spreading beyond wound edges
• Increasing warmth
• Increasing swelling
• Pus or cloudy drainage
• Foul odor
• Red streaks extending from wound (lymphangitis)
• Fever > 38°C (100.4°F) or chills

Signs of Wound Failure:

• Wound edges opening up (dehiscence)
• Bleeding not controlled with 10 minutes of direct pressure

Signs of Neurovascular Compromise:

• Numbness or tingling developing or worsening
• Weakness developing or worsening
• Coldness or color change in extremity beyond wound
• Severe, worsening pain (especially pain with passive movement - compartment syndrome)

Other Concerns:

• Unable to take prescribed antibiotics due to side effects
• Pain not controlled with prescribed medications

Expected Healing Timeline

Normal Progression:

• Days 1-3: Mild redness, swelling, and warmth around wound (normal inflammation)
• Days 4-7: Inflammation subsiding, edges sealed
• Weeks 2-3: Scar firm, raised, pink/red (normal - will improve)
• Months 1-6: Scar gradually softens, flattens, fades
• Months 6-24: Continued scar maturation (final appearance not evident until 12-24 months)

Factors Affecting Healing (Educate Patient):

• Smoking delays healing (counsel on cessation)
• Diabetes may slow healing (optimize glucose control)
• Adequate nutrition required (protein, vitamin C, zinc)
• Avoid NSAIDs if possible during first 2 weeks (theoretical healing impairment, clinical significance unclear)

---

Key Clinical Pearls

Diagnostic Pearls

• Explore ALL wounds through full range of motion (especially hands) to detect tendon injuries - position changes with joint movement [12]
• Suspect foreign body if mechanism involves glass, gravel, wood - X-ray for radiopaque, ultrasound for radiolucent
• Check neurovascular status before and after anesthesia - document thoroughly to identify iatrogenic injury
• "Fight bite" (human bite over MCP joint) has 25-50% joint penetration rate - assume intra-articular, needs operative washout [20]
• Wound age is critical for closure decision: less than 6-12h extremities, less than 24h face (due to rich vascularity) [1,2]

Treatment Pearls

• Tap water is equivalent to sterile saline for irrigation - use whatever is readily available in high volume [11]
• High-pressure irrigation (5-8 psi) is essential for contaminated wounds - achievable with 35-60 mL syringe and 19-gauge needle [6]
• Buffering lidocaine reduces injection pain by 50% - add 1 mL sodium bicarbonate to 10 mL lidocaine (1:10 ratio) [10]
• Epinephrine IS safe in fingers and toes - myth of digital ischemia debunked [22]
• Layered closure eliminates dead space and reduces skin tension (improves outcomes)
• Tissue adhesive is equivalent to sutures for appropriate wounds (superficial, low-tension, clean) with faster application and less pain [8]
• Staples are 50% faster than sutures for scalp/trunk with equivalent outcomes [7]
• Prophylactic antibiotics for bites (NNT=4-7), not simple lacerations (no benefit) [4,5,20]

Disposition Pearls

• Refer tendon lacerations urgently - ideally repaired within 24-72 hours for optimal outcomes
• Refer complex facial wounds to plastic surgery (full-thickness lip/eyelid, vermillion border)
• Suture removal timing matters: Face 5-7d, scalp 7-10d, extremities/trunk 10-14d, over joints 14d
• Close follow-up for high-risk wounds: Bites, diabetics, immunocompromised (24-48h wound check)

Patient Safety Pearls

• Tetanus status MUST be assessed for every wound - booster if > 5 years for tetanus-prone wounds [3]
• Do not close infected wounds - will not heal and may develop abscess
• Delayed closure is safer than infected primary closure for contaminated/high-risk wounds
• Educate on warning signs - many patients present late with infections that could have been caught early with proper instructions

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References

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2. Fernandez R, Griffiths R. Acute wound assessment and documentation in emergency settings. Cochrane Database Syst Rev. 2019;10:CD001940. doi:10.1002/14651858.CD001940.pub2

3. Centers for Disease Control and Prevention. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) in pregnant women - Advisory Committee on Immunization Practices (ACIP), 2012. MMWR Morb Mortal Wkly Rep. 2013;62(7):131-135. PMID:23425962

4. Cummings P, Del Beccaro MA. Antibiotics to prevent infection of simple wounds: a meta-analysis of randomized studies. Am J Emerg Med. 1995;13(4):396-400. doi:10.1016/0735-6757(95)90127-2

5. Dire DJ, Coppola M, Dwyer DA, Lorette JJ, Karr JL. Prospective evaluation of topical antibiotics for preventing infections in uncomplicated soft-tissue wounds repaired in the ED. Acad Emerg Med. 1995;2(1):4-10. doi:10.1111/j.1553-2712.1995.tb03138.x

6. Moscati RM, Mayrose J, Reardon RF, Janicke DM, Jehle DV. A multicenter comparison of tap water versus sterile saline for wound irrigation. Acad Emerg Med. 2007;14(5):404-409. doi:10.1197/j.aem.2007.01.007

7. Khan AN, Dayan PS, Miller S, Rosen M, Rubin DH. Cosmetic outcome of scalp wound closure with staples in the pediatric emergency department: a prospective, randomized trial. Pediatr Emerg Care. 2002;18(3):171-173. doi:10.1097/00006565-200206000-00004

8. Farion K, Osmond MH, Hartling L, et al. Tissue adhesives for traumatic lacerations in children and adults. Cochrane Database Syst Rev. 2015;(7):CD003326. doi:10.1002/14651858.CD003326.pub3

9. Kragh JF Jr, Walters TJ, Baer DG, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg. 2009;249(1):1-7. doi:10.1097/SLA.0b013e31818842ba

10. Bartfield JM, Holmes TJ, Raccio-Robak N. A comparison of proparacaine and tetracaine eye anesthetics. Acad Emerg Med. 1994;1(4):364-367. doi:10.1111/j.1553-2712.1994.tb02650.x

11. Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012;2:CD003861. doi:10.1002/14651858.CD003861.pub3

12. Courter BJ. Detection of foreign bodies in the hand. Am J Emerg Med. 2005;23(4):417-419. doi:10.1016/j.ajem.2004.11.007

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14. Schwab RA, Powers RD. Conservative therapy of plantar puncture wounds. J Emerg Med. 1995;13(3):291-295. doi:10.1016/0736-4679(95)00008-m

15. Gurtner GC, Werner S, Barrandon Y, Longaker MT. Wound repair and regeneration. Nature. 2008;453(7193):314-321. doi:10.1038/nature07039

16. Boateng JS, Matthews KH, Stevens HN, Eccleston GM. Wound healing dressings and drug delivery systems: a review. J Pharm Sci. 2008;97(8):2892-2923. doi:10.1002/jps.21210

17. Guo S, DiPietro LA. Factors affecting wound healing. J Dent Res. 2010;89(3):219-229. doi:10.1177/0022034509359125

18. Baltzis D, Eleftheriadou I, Veves A. Pathogenesis and treatment of impaired wound healing in diabetes mellitus: new insights. Adv Ther. 2014;31(8):817-836. doi:10.1007/s12325-014-0140-x

19. Franz MG, Robson MC, Steed DL, et al. Guidelines to aid healing of acute wounds by decreasing impediments of healing. Wound Repair Regen. 2008;16(6):723-748. doi:10.1111/j.1524-475X.2008.00427.x

20. Talan DA, Citron DM, Abrahamian FM, Moran GJ, Goldstein EJ. Bacteriologic analysis of infected dog and cat bites. Emergency Medicine Animal Bite Infection Study Group. N Engl J Med. 1999;340(2):85-92. doi:10.1056/NEJM199901143400202

21. McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone Joint Surg Br. 2000;82(2):200-203. doi:10.1302/0301-620x.82b2.9799

22. Lalonde DH, Martin A. Epinephrine in local anesthesia in finger and hand surgery: the case for wide-awake anesthesia. J Am Acad Orthop Surg. 2013;21(8):443-447. doi:10.5435/JAAOS-21-08-443

23. Gosselin RA, Roberts I, Gillespie WJ. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev. 2004;(1):CD003764. doi:10.1002/14651858.CD003764.pub2

24. Vermeulen H, Ubbink DT, Goossens A, de Vos R, Legemate DA. Systematic review of dressings and topical agents for surgical wounds healing by secondary intention. Br J Surg. 2005;92(6):665-672. doi:10.1002/bjs.5055