Wound treatment

Wounds are disruptions of the normal structure and function of skin and underlying soft tissue caused by trauma or chronic mechanical stress (e.g., decubitus ulcers). Wounds can be acute or chronic and open or closed. All wounds should be assessed for the extent of injury, degree of contamination, and injury to adjacent neurovascular structures and bones. Patients with multiple wounds should be screened for concurrent injuries to deeper structures or organs, as well as complications such as rhabdomyolysis, compartment syndrome, and venous thromboembolism. Open wounds are managed with cleaning, removal of devitalized tissue, and, if feasible, wound closure. The type and timing of wound closure depend on the degree of contamination and how much time has passed since the injury. Options for wound closure range from glue, wound closure strips, and suturing to complex plastic surgery repairs such as skin grafting. Closed musculoskeletal wounds are managed according to the POLICE principle. Chronic wounds and ulcers can often be treated conservatively; however, in severe or nonhealing wounds, surgical intervention, including debridement and skin grafting, may be necessary. Management of the underlying cause (e.g., diabetes, chronic venous disease) is imperative to enable healing of chronic wounds. Wound complications include hematomas, seromas, infection, and delayed healing. Complications of abdominal surgical wounds additionally include wound dehiscence and evisceration, and fistulas of the GI tract.

Acute wound management is covered in detail here. See the articles on “Decubitus ulcers” and “Venous ulcers” for the management of these chronic wounds. Needlestick injuries are also discussed separately.

Acute vs. chronic wounds ^[1]

• Acute wound: a disruption of the skin and/or underlying soft tissue that has a well-organized healing process with predictable tissue repair
  • Stab wounds
  • Lacerations: skin compression and splitting with irregular and macerated edges
  • Avulsion injury ^[2]
    • Traumatic detachment of the skin and subcutaneous fat caused by a shearing force
    • Can range from the detachment of small skin flaps to complete degloving of an extremity
  • Bruises
    • Rupture of blood vessels within the skin as a result of direct trauma, with the surface of the skin remaining intact
    • Can also occur in muscles, bones, and internal organs
• Chronic wound: a wound with an impaired healing process, usually involving a prolonged or excessive inflammatory phase, persistent infections, formation of drug-resistant microbial biofilms, and the inability of cells to respond to reparative stimuli. All chronic wounds begin as acute wounds.
  • Vascular ulcers (venous ulcers and arterial ulcers)
  • Diabetic ulcers
  • Decubitus ulcers

Open vs. closed wounds ^[3]

• Open wound: a wound with skin breakage and exposure of underlying tissue to the outside environment
  • Lacerations
  • Gunshot wounds
  • Punctures
• Closed wound: a wound with intact skin, and underlying tissue not directly exposed to the outside environment
  • Contusions
  • Hematomas
  • Crush injuries
  • Blunt trauma

This section covers the basics of wound management. See “Management of trauma patients,” “Blunt trauma,” and “Penetrating trauma” for further details.

Initial management ^[4][5][6]

• Perform rapid primary survey to identify other severe or concealed injuries.
  • Consider hemostatic measures for active bleeding.
  • Screen for life-threatening or limb-threatening complications.
• Assess the wound for associated neurovascular or musculoskeletal injuries and degree of contamination.
• Consider the need for additional diagnostics, specialty consults, and specific management steps depending on the type of wound and associated injuries.
  • See “Management of open wounds” and “Management of closed wounds.”
  • Suspected open fracture or wound overlying a joint line
    • Splint the affected joint or bone
    • Begin general management of fractures as needed.

Hemorrhage control

• Actively hemorrhaging wounds: Perform hemostatic measures.
  • Mechanical hemostasis: local pressure over the wound, packing the wound, or application of a tourniquet proximal to the site of bleeding
  • Pharmacological hemostasis: local hemostatic agents (e.g., epinephrine or fibrin) or systemic antifibrinolytics (e.g., tranexamic acid)
  • Surgical hemostasis: thermal coagulation (e.g., electrocautery) or ligation (e.g., sutures or hemostatic clips) of the bleeding vessel(s)
  • Interventional radiology: angiographic embolization
• Hemorrhagic shock: Resuscitate with blood products. ^[7]
• Coagulopathy
  • Obtain coagulation studies in patients with suspected or known coagulation disorders.
  • Administer anticoagulant reversal in patients with ongoing or severe hemorrhage.
  • In severe wound(s), consider withholding further doses of antithrombotics in consultation with specialists.

Assessment of the wound

• Consider local or regional anesthesia or systemic analgesia before wound exploration (see “Pain Management” for drugs and dosages).
• Assess location, age, depth, width, length of the wound(s), and extent of devitalized tissue.
• Assess for degree of contamination (i.e., clean wounds or dirty wounds).
• Assess for concurrent injuries.
  • Vascular injuries: Examine pulses and capillary refill time distal to the wound; assess the 6 Ps for signs of acute limb ischemia.
  • Peripheral nerve injuries: Examine sensation and motor function distal to the wound before administering anesthesia.
  • Bone, cartilage, or meniscal injury: Assess for signs of fracture and range of motion (active and passive) of the underlying joint or bone.
  • Tendon injuries: Assess movement and range of motion of the respective muscles (see “Biceps tendinopathy and biceps tendon rupture,” “Achilles tendon rupture,” and “Patellar tendon rupture” for details).

Penetrating wounds, open fractures, and wounds with extensive devitalized tissue are risk factors for tetanus.

Diagnostics ^[4][8]

• The diagnostic approach depends on the patient's hemodynamic status and the pretest probability of the suspected injury and associated complications.
• Initiate appropriate management immediately if a life-threatening and/or limb-threatening complication (e.g., coagulopathy, compartment syndrome, cardiac tamponade) is suspected.

Truncal wounds and/or multisystem complications (potentially life-threatening)

Consider the following tests based on clinical suspicion. See also “Urgent diagnostics for trauma patients.”

• Internal injuries: Obtain imaging of relevant body parts, e.g.
  • CT head and/or cervical spine to assess patients with suspected traumatic brain injury or C-spine injury
  • FAST and/or CT chest, abdomen, and/or pelvis to check for intraabdominal organ injury in patients with an abdominal injury
  • Transthoracic echocardiography to exclude cardiac tamponade in patients with thoracic injury
• Severe hemorrhage: Obtain CBC, coagulation panel, type and screen.
• Crush injuries: Obtain a BMP, muscle enzymes, and urinalysis to screen for rhabdomyolysis and crush syndrome (see “Diagnostics for rhabdomyolysis” for details). ^[9]
• Renal trauma: Perform urinalysis to check for hematuria.

Extremity wounds and/or local complications (potentially limb-threatening)

Consider the following tests based on clinical suspicion.

• Fracture(s), dislocations, implanted foreign body: Obtain X-ray of the affected region (see “Radiographic signs of a fracture”). ^[10]
• DVT or pulmonary embolism: Obtain lower extremity venous ultrasound and/or CT pulmonary angiography.
• Compartment syndrome: Perform compartment pressure measurements.
• Neurovascular injuries: Consider the following if the clinical examination is abnormal
  • Doppler ultrasound and/or angiography
  • Electroneurography or electromyography ^[11]

Other investigations

• Screen for risk factors that impact wound healing (e.g., diabetes mellitus, anemia) as clinically indicated.
• Consider further evaluation for nonaccidental trauma in at-risk patients (See “Sexual violence, domestic violence, elder abuse” and “Child abuse.”)

Specialist consults

Consultation protocols vary among hospitals depending on the available specialist expertise and the agreements between specialties.

• General surgery for:
  • Trauma (including polytrauma)
  • Large or multiple wounds
  • Blunt or penetrating abdominal injury
  • Wounds potentially involving the anal sphincter (perineal injury)
• Orthopedic surgery for:
  • Wounds overlying a fracture or dislocation
  • Damage to underlying structures (such as vessels, nerves, tendons, or joint capsule)
• Plastic surgery for:
  • Multiple or complex facial wounds (e.g., involving the lips or eyelids)
  • Extensive injuries to the hands (may also be managed by orthopedics)
• Cardiothoracic surgery for blunt or penetrating chest injury
• Vascular surgery for suspected or confirmed vascular injury (transection, aneurysm, thrombosis)
• Neurosurgery for suspected TBI
• Urology and/or gynecology for genitourinary trauma

• Determine if the patient requires a full trauma workup (see “Management of trauma patients”).
• Active bleeding: Perform hemostatic measures.
• Provide adequate analgesia.
• Screen for life-threatening or limb-threatening complications (e.g., pneumothorax, rhabdomyolysis, compartment syndrome).
• Assess for concurrent injuries.
• Assess wound characteristics and age.
• Administer tetanus prophylaxis if necessary.
• Obtain laboratory studies and imaging as needed.
• Order specialist consults as needed; consider management in the OR.
• Clean the wound.
• Treat as appropriate.
  • Clean, recent open wounds: primary closure
  • Older, contaminated open wounds: secondary closure
  • Closed musculoskeletal wounds: POLICE principle
• Immobilize fractures and wounds over joints.
• Screen for risk factors for delayed wound healing.

Approach

See “Acute wound management” for initial assessment and emergency measures.

• Clean, debride, and irrigate all open wounds. ^[6]
• Consider closure of acute open wounds depending on wound characteristics.
  • Identify if the wound should be repaired by a specialist (see “Specialist consults”).
  • Wound edges can be approximated: Consider primary closure or delayed primary closure.
  • Wounds with extensive tissue loss: Consider referral to plastic surgery for skin grafting.
• Consider antibiotics for acute open wounds depending on the wound and patient characteristics.
  • Consider prophylaxis for wounds at high risk of infection including certain bite wounds.
  • Treat infected wounds.
  • Select antibiotics based on the likely pathogens and local resistance patterns.
• Consider tetanus prophylaxis (tetanus toxoid ± human tetanus immunoglobulin ). ^[4][12]

When evaluating a wound for primary or secondary closure, consider the length of time that has elapsed since injury, wound characteristics, and comorbidities.

Refer patients with the following wounds for repair by a specialist: multiple, large, and/or complex wounds (e.g., facial wounds involving the eyelids, extensive hand injuries); wounds with damage to underlying structures (e.g., vessels, nerves, tendons); and wounds in the genitourinary tract.

Follow-up

• Arrange regular follow-up to assess wound healing, especially of complicated wounds.
• Ensure regular dressing changes.
• Educate patients on wound care.
  • Keep the wound clean and dry.
  • Check regularly for signs of wound infection.
  • Seek medical attention if the wound deteriorates.
• Schedule suture/staple removal as needed; always assess wound healing before removing sutures/staples. ^[4]
  • In otherwise healthy individuals, the timing of suture/staple removal depends on the location of the wound.
    • Face: after 3–5 days
    • Scalp and trunk: after 7–10 days
    • Extremities: after 10–14 days
  • Timing of suture/staple removal may be longer for complex wounds or if there are risk factors for delayed wound healing.

Primary wound closure

• Definition: closure of recent wounds by approximation of the wound edges, allowing for healing by primary intention
• Indications
  • Clean wounds that have a low risk of infection and edges that can be approximated without tension
  • Recent wounds, typically described as: ^[6][13]
    • Within 6–10 hours of injury on the extremities
    • Within 10–12 hours of injury on the scalp and face
• Procedure ^[6]
  1. Assemble equipment, e.g., cleaning supplies, local anesthesia, sterile drapes.
  2. Clean the wound and create a sterile field around it. ^[6]
  3. Consider administering local anesthesia depending on the planned method of closure.
  4. Inspect the wound.
  5. Excise wound edges (if necessary) and irrigate the wound.
  6. Perform tension-free approximation of the wound edges using any of the following:
     • Suture material
     • Staples
     • Tissue adhesive
     • Wound closure strips
     • Hair apposition technique ^[14]
  7. Apply sterile dressing.
  8. Immobilize the affected extremity, if necessary.
• Antibiotics ^[15]
  • Minor, uncontaminated injuries: Antibiotic prophylaxis is not routinely required.
  • Wounds at high risk of infection: Consider antibiotic prophylaxis.
• Wound healing
  • Occurs by primary intention
  • Wound healing occurs with minimal inflammation and minimal to no granulation tissue formation.
  • Organ-specific tissue forms at the site of healing
  • Minimal (hairline) scar formation

Tissue adhesive ^[16][17]

• Indications: simple, superficial wounds suitable for primary wound closure in adults and children
• Contraindications
  • Deep wounds
  • Jagged or stellate wounds
  • Punctures, bites, or crush wounds
  • Mucosal surfaces
  • Wounds under tension
  • Heavy or continued bleeding
• Procedure
  1. Clean the wound.
  2. Ensure hemostasis and dry surrounding skin.
  3. Closely approximate the wound edges.
  4. Apply a thin layer of adhesive over the length of the wound.
  5. Allow time to dry before considering additional layers.
  6. After drying, apply a nonocclusive dressing.
  7. Allow 5–10 days for the adhesive to slough off.
• Pitfalls and troubleshooting
  • Glue runs off and/or adheres to unintended surface.
    • Position the patient such that any excess adhesive will not run into sensitive areas (e.g., the eyes).
    • Place wet gauze or a petroleum jelly barrier to prevent runoff of excess adhesive.
    • Adhesive that has set can be removed using antibiotic ointment, petroleum jelly, or acetone.
  • Wound dehiscence or poor cosmesis (e.g., due to adhesive sloughing off too early)
    • Avoid using only adhesive for wounds under tension or areas that move significantly with regular activity.
    • Hold the wound edges in close approximation until the adhesive has dried.
    • Instruct patients to avoid the use of ointments, rubbing, and immersion of the wound.

Secondary wound closure

• Definition: leaving a wound to heal by secondary intention (i.e., without approximating the wound edges)
• Indications
  • Infected wounds, e.g., surgical site infection ^[18]
  • Wounds at high risk of infection, e.g., wounds with implanted foreign bodies ^[6]
  • Bite wounds that do not meet the criteria for primary closure (see “Bite wounds” for details)
  • Wounds older than the time frame within which primary closure can be safely performed.
  • Large wounds with irregular edges that cannot be approximated without tension
• Goal: debridement to remove devitalized tissue; removal of contaminants and foreign bodies that may disrupt healing. ^[6]
• Procedure ^[6]
  1. Administer; local, regional, or general anesthesia.
  2. Clean via pressured irrigation using warm, isotonic saline. ^[6][10]
  3. Perform surgical (sharp) debridement: removal of devitalized tissue and debris to allow for wound healing
  4. Ensure drainage (e.g., silicone/rubber drains, strip of gauze) of deep wounds.
  5. Apply moist dressing.
  6. Immobilize the affected extremity, if necessary.
• Further treatment
  • Wounds at high risk of infection: Consider antibiotic prophylaxis.
  • Infected wounds: Administer antibiotics (see “Empiric antibiotic therapy for skin and soft tissue infections”).
  • Regular dressing changes
  • Reevaluation for delayed primary closure (if needed) after ∼ 3 days
  • Consider negative pressure wound therapy (NPWT) as an adjunct to stimulate the healing process for large wounds. ^[13][15]
• Wound healing
  • Occurs by secondary intention
  • Usually accompanied with pronounced inflammation
  • Takes longer than wounds that have been repaired with primary closure
  • Requires the formation of granulation tissue
  • The wound bed is replaced with increased proliferation of fibroblasts.
  • Pronounced scar formation

Tetanus prophylaxis is usually required for most wounds that need secondary closure.

Tertiary wound closure (delayed primary closure)

• Definition: surgical closure of a wound after healing by secondary intention has already begun; also known as healing by tertiary intention
• Indications
  • Clean wounds with healthy edges in patients presenting after the time frame within which primary closure can be safely performed.
  • Contaminated wounds left to heal by secondary intention and with no signs of infection after 3–5 days ^[6]
• Procedure
  1. Clean the wound and debride any areas of devitalized tissue.
  2. Close the wound using the methods for primary wound closure outlined above.
• Wound healing
  • Occurs by tertiary intention
  • Results in a larger scar than with primary or secondary closure due to an interruption in normal wound healing

Contaminated wounds can be closed (i.e., by delayed primary closure) if there are no signs of infection after a few days of observation.

Wounds at high risk of infection ^[4][6][19]

If one or more of the following high-risk features are present, antibiotic prophylaxis should be considered.

• Wound characteristics
  • Complicated wounds, e.g., crush injuries, deep puncture wounds
  • Significant contamination, e.g., with feces, saliva, or dirt
  • Implanted foreign bodies
• Wound location
  • Poorly vascularized areas, e.g., feet, hands
  • Suspected extension to bones and joints, e.g., open fractures
  • Areas with significant bacterial colonization, e.g., armpits, genitals, intraoral wounds ^[20]
• Patient characteristics
  • Advanced age
  • Immunosuppression
  • Significant comorbidities, e.g., diabetes mellitus

Antibiotic prophylaxis ^[21]

• A single dose is usually sufficient for superficial wounds, while deep wounds and open fractures may require longer regimens.
• Specific regimes depend on the type and location of the wound, e.g:
  • Bite wounds: See “Antibiotic prophylaxis and therapy for bite wounds.”
  • Gaping intraoral lacerations: Antibiotics should cover oral flora, topical antibiotics (e.g., bacitracin) may be considered. ^[4][20]
  • Puncture wounds of the foot: Consider adding agents that cover Pseudomonas aeruginosa and/or MRSA. ^[4]

Most wounds that can undergo primary closure do not require antibiotic prophylaxis, except wounds at high risk of infection.

Antibiotic therapy ^[21]

• In general, infected wounds are treated with empiric antibiotic therapy for skin and soft tissue infections.
• Specific regimes may be necessary for certain types of wounds, including:
  • Infected marine wounds ^[4][12]
    • Superficial infections (e.g., erysipelas): Consider penicillins or macrolides.
    • Purulent infections (e.g., abscess): Consider penicillinase-resistant penicillins or 1^st generation cephalosporins
    • Necrotizing infections, patients with chronic wounds or immunocompromise: broad-spectrum antibiotics with activity against anaerobes, gram-positive aerobes, and gram-negative bacteria
  • Infected bite wounds: See “Antibiotic prophylaxis and therapy for bite wounds.”

Obtain cultures in all patients with infected wounds.

• See “Acute wound management” for initial assessment, emergency measures, and diagnostics.
• Ensure proper analgesia (see “Pain management” for drugs and dosages).
• Treat concomitant injuries.
• Screen for and manage complications (e.g., compartment syndrome, deep vein thrombosis, rhabdomyolysis) ^[8][9]
• Minimize further inflammation: POLICE principle for acute musculoskeletal injuries (e.g., injuries to bones, tendons, or ligaments) ^[22]
  • Protection
  • Optimal Loading
  • Ice
  • Compression
  • Elevation

Skin grafting ^[23]

Skin grafts may be used to close wounds, prevent fluid and electrolyte loss, and reduce bacterial burden and infection.

Full thickness skin graft (FTSG)

• Graft: epidermis and dermis (including dermal appendages), usually obtained from areas of redundant and pliable skin (e.g., groin, lateral thigh, lower abdomen, lateral chest)
• Indications: small, uncontaminated, well-vascularized wounds
• Advantages: good postoperative cosmetic outcome
• Disadvantages: high risk of necrosis, secondary injury to the donor area

Split-thickness skin graft (STSG)

• Graft: epidermis and upper part (¼–¾) of the dermis (without dermal appendages)
• Indications: many uses; resurface large wounds and mucosal deficits, line cavities, close donor sites of flaps, treat large chronic wounds
• Advantages: heals well, only superficial secondary defect in donor area, which does not have to be covered
• Disadvantages: scar formation when graft heals, skin pigmentation change, tendency to contract, more fragile
• Subtype: mesh graft
  • Graft can be stretched 3–6 times its original size by grid‑like incisions.
  • Suitable for large skin defects

Skin grafts are contraindicated in the case of contaminated wounds or insufficient blood supply.

Composite graft ^[24]

• Graft: a graft containing multiple structures, such as skin and other structures like muscles, bones, or cartilage
• Indications: distal fingertip amputations, nasal reconstructions, ear reconstructions
• Advantages: heals well, usually includes pedicle containing blood supply, aesthetically pleasing
• Disadvantages: higher infection rate, increased risk that graft does not take compared to local flaps

Amputations ^{[25][26][27][28]}

An amputation is the surgical or traumatic severance of a body part.

Types

• Complete amputation: the body part is totally severed
• Partial amputation: some soft tissue remains connected to the affected body part and to the rest of the body
• Surgical amputation: the surgical removal of a body part
  • Indications
    • Gangrene (e.g., due to diabetes mellitus, bacterial infection such as Clostridium perfringens, or peripheral arterial disease)
    • Infection (e.g., osteomyelitis)
    • Malignancy (e.g., osteosarcoma)
    • Irreparable trauma injury (e.g., comminuted fracture of a limb)
    • Severely burned limbs
    • Compartment syndrome
    • Severe contractures
    • Congenital anomalies
    • Severe thermal and/or electrical injury
  • Procedure
    1. Preparation and disinfection of the limb
    2. Preparation of skin flaps (for closing the wound)
    3. Dissection of the fascia, muscles, vessels, and nerves
    4. Transsection of the bone (if necessary)
    5. Smoothing of the edges of the bone
    6. Fixation of the remaining muscles along the bone
    7. Suturing and closing of the fascia, subcutaneous tissue, and the skin (see “Acute wound treatment”)
• Traumatic amputations: Most traumatic amputations are unintentional, resulting from factory, farm, or power tool injuries.
  • Complete fingertip amputation management ^[26]
    1. Control bleeding by placing direct pressure on the wound and raising the injured area.
    2. Gently clean the amputated part with sterile saline solution.
    3. Cover with gauze dampened with saline.
    4. Place in a watertight bag.
    5. Place the bag in an ice bath in a sealed container.
    6. Go to hospital for urgent assessment.
    7. Reimplantation is more likely to be performed in case of:
       • Short ischemia time
       • Thumb and index finger involvement
       • Children
       • Dominant limb involvement
       • Patients with occupations requiring fine motor skills
       • Upper limb amputations > lower limb amputations (as more prostheses are available for lower limb)

Do not allow the amputated part to be in direct contact with ice, because this can cause further damage.

Complications

• Wound infection: stump pain, erythema, fever, and wound drainage
• Deep vein thrombosis
• Stump hematoma
• Stump ulcer
  • Etiology: most commonly due to friction and repetitive pressure from a prosthesis with a suboptimal fit
  • Risk factors: conditions associated with poor wound healing (e.g., diabetes, peripheral neuropathy, vasoconstriction)
  • Management of noninfected stump ulcer: pressure relief, skin care, frequent wound checks, and maintaining an optimal fit between prosthetic socket and residual limb
• Edema
• Contractures leading to deformities and diminished function in the joint adjacent to the stump
• Skin necrosis around the vital stump
• Phantom limb pain: the sensation of a lost limb after amputation, which often feels painful
• Phantom limb sensation: the sensation that an amputated or lost limb is still intact, often involving pain (phantom limb pain)
• Residual limb pain: stump pain following an amputation

Bite wounds ^[29]

Bite wounds (caused by animals, e.g., cat bites , or human bites e.g., “fight bite”) are associated with an increased risk of infection, as the bacterial flora of the oral cavity hinders wound healing.

• Common pathogens: Streptococcus, Staphylococcus, Pasteurella multocida, Haemophilus influenzae, Capnocytophaga canimorsus, Eikenella corrodens ; , anaerobic bacteria
• Rabies risk assessment
  • Must be considered in case of bite wounds by animals, such as:
    • Dog bites
    • Bats, raccoons, skunks, foxes, mongooses
  • If rabies is suspected, active and passive immunization according to vaccine recommendations should be performed.
• Wound management ^[4][30]
  • Stabilization with direct pressure to stem bleeding, and neurovascular assessment of areas distal to wound
  • Irrigation and debridement
  • Sterile wound dressing
  • Primary surgical closure if wound meets all of the following criteria :
    • Clinically uninfected
    • < 12 hours old (< 24 hours if on the face)
    • Locations other than the hand or foot
  • Allow spontaneous closure (secondary wound closure) if:
    • Cat or human bite not on the face
    • Puncture wounds
    • Wounds > 12 hours old (> 24 hours if on the face)
    • Bites involving the hands or feet
• Tetanus protection
  • If patient was adequately vaccinated (successful initial immunization and booster vaccinations), there is no need for additional protection.
  • If vaccine status is outdated or unknown, see “Tetanus prophylaxis”.

Antibiotic prophylaxis and therapy for bite wounds ^[30]

Indications ^[4]

• Administer antibiotic therapy for all infected animal or human bite wounds.
• Administer antibiotic prophylaxis for 3–5 days in patients with:
  • Canine bites:
    • On the hands or face
    • With suspected periosteum or joint capsule penetration
    • Requiring closure ^[4]
    • In immunocompromised patients
  • Any bites extending through the epidermis from either of the following:
    • Cats
    • Humans
    • Others: monkeys, pigs, horses, ferrets, camels, and bears
• See also: “Wounds at high risk of infection.”

Agents

Use broad‑spectrum antibiotics with activity against aerobic and anaerobic pathogens.

• Animal bites
  • First-line: amoxicillin-clavulanate ^[30]
  • Alternatives include a 2^nd or 3^rd generation cephalosporin (e.g., cefuroxime , ceftriaxone ) PLUS anaerobic coverage (clindamycin or metronidazole ) if required. ^[30]
• Human bites: amoxicillin-clavulanate or ampicillin-sulbactam ^[30]

Bite wounds should receive the same treatment as open dirty wounds.

Stab wounds

• When performing first aid, do not remove the foreign body from the wound, as this could stop the object's sealing and tamponading effect, which could result in bleeding.
• Removal in a hospital setting with staff prepared for immediate surgical intervention
• Treatment: see “Penetrating trauma”

Miscellaneous

• Needlestick injuries
• Decubitus ulcers

Life-threatening and limb-threatening complications ^[8][9]

See also “Management of trauma.”

• Severe hemorrhage: coagulopathy (e.g. due to consumptive-type DIC)
• Extremity trauma: major vascular injury, compartment syndrome, DVT, pulmonary embolism
• Crush injury: compartment syndrome, rhabdomyolysis
• Thoracic injury: pneumothorax, cardiac tamponade
• Abdominal injury: hemoperitoneum (e.g., due to solid organ injury), pneumoperitoneum (e.g., due to hollow viscus perforation)
• Head injury: traumatic brain injury, C-spine injury

Other wound complications

• Bacterial wound infections
• Tetanus
• Associated tendon, nerve, or vascular injury
• Scarring, fibrosis, and contractures
• Retained foreign bodies

Complications of surgical incisions

• Surgical site infection
• Intestinal fistulas
• Wound dehiscence: the spontaneous separation of wound edges following surgical wound repair
  • Can be superficial (skin and subcutaneous tissue) or deep (fascial)
  • Common after abdominal surgery; see “Fascial dehiscence.”
  • Consult surgery for treatment, e.g., secondary wound closure.
• Hematomas and seromas

We list the most important complications. The selection is not exhaustive.

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