From the Guidelines
For a 42-year-old male with multiple comorbidities presenting with a palm laceration from a clean object at 8 hours post-injury, I recommend delayed primary closure with thorough wound irrigation and debridement, as this approach prioritizes minimizing morbidity, mortality, and optimizing quality of life by reducing the risk of infection and promoting optimal wound healing. The wound should be irrigated with sterile normal saline (at least 500-1000 mL) under pressure using a 19-gauge needle and 35 mL syringe to remove debris and bacteria, as suggested by general wound care principles 1. Debridement of devitalized tissue should be performed, followed by loose approximation of wound edges using non-absorbable sutures like nylon 4-0 or 5-0. Prophylactic antibiotics are indicated due to the high-risk location, delayed presentation, and comorbidities; according to the practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of america 1, amoxicillin-clavulanate or cephalexin can be considered for clean lacerations, but given the specific context of a palm laceration and the need for broader coverage, cephalexin 500 mg orally four times daily for 5-7 days is a reasonable choice. The wound should be covered with a sterile, non-adherent dressing changed daily with wound inspection for signs of infection. Tetanus prophylaxis should be administered if the patient's immunization status is incomplete or unknown. Hand elevation and limited use are important to reduce swelling and promote healing. The patient should be instructed to return immediately if signs of infection develop (increasing pain, redness, swelling, purulent drainage, fever). This approach is supported by the principles outlined in the practice guidelines for the diagnosis and management of skin and soft tissue infections 1, which emphasize the importance of wound care, appropriate use of antibiotics, and monitoring for signs of infection in managing skin and soft tissue infections.
From the Research
Treatment and Management
The recommended treatment and management for a 42-year-old male with multiple comorbidities presenting with a palm laceration of the left hand due to a clean object, approximately 8 hours post-injury, with delayed closure and high risk of infection include:
- Administering antibiotics preventatively to reduce the risk of infection, as seen in the patient's case where antibiotics were prescribed due to the patient's medical history and delayed closure 2, 3, 4, 5, 6
- Providing wound care instructions to the patient to ensure proper wound healing and prevent infection
- Discussing strict return precautions with the patient to monitor for any signs of infection or complications
Antibiotic Prophylaxis
The use of antibiotic prophylaxis in clean-contaminated surgery has been shown to be effective in reducing wound infection rates, as demonstrated in studies comparing amoxicillin-clavulanate with other antibiotic regimens 3, 5, 6
- Amoxicillin-clavulanate has been shown to be as effective and safe as other antibiotic regimens in preventing wound infection and may provide better protection against intra-abdominal infections 5
- The choice of antibiotic prophylaxis should be based on the patient's individual risk factors and medical history, as well as the type of surgery or injury
Follow-up Care
Follow-up care is crucial in monitoring the patient's wound healing and detecting any potential complications early on
- The patient should be advised to return for suture removal and follow-up in a timely manner, as seen in the patient's case where he was advised to return in 10 days for suture removal and follow-up in 48 hours for recheck of laceration
- The patient should be educated on signs of infection, such as increased redness, swelling, or purulent discharge, and instructed to seek medical attention immediately if any of these symptoms occur