Should you close a dirty or contaminated wound?

Management of Dirty or Contaminated Wounds

Dirty or contaminated wounds should not be closed primarily, except for facial wounds, which may be closed after copious irrigation, careful debridement, and prophylactic antibiotics. 1, 2

Initial Assessment and Classification

• Evaluate the wound for:

  • Type and mechanism of injury
  • Depth and extent of contamination
  • Time since injury
  • Presence of foreign bodies
  • Involvement of underlying structures (tendons, nerves, vessels)
  • Signs of infection

• Contaminated wounds include:

  • Wounds >8 hours old
  • Grossly contaminated wounds (soil, feces, saliva)
  • Puncture wounds
  • Crush injuries with devitalized tissue
  • Animal or human bites

Management Protocol

Step 1: Wound Cleaning and Debridement

• Irrigate abundantly with sterile saline or potable tap water to eliminate contaminants 2
• Use pressure irrigation to effectively remove debris and bacteria
• Perform thorough debridement of all devitalized tissue 2
• Remove all foreign material

Step 2: Wound Closure Decision

For non-facial contaminated wounds:

• Do not close primarily 1, 2
• Options include:
  1. Delayed primary closure (preferred approach): Leave wound open for 2-5 days, then close if no signs of infection 2, 3
  2. Secondary intention: Allow wound to heal by granulation
  3. Wound approximation: Use Steri-Strips without formal closure 2, 4

For facial wounds only:

• May consider primary closure due to:
  • Better blood supply
  • Cosmetic importance
  • Lower infection rates compared to other locations 2
• Must include:
  • Copious irrigation
  • Careful debridement
  • Prophylactic antibiotics 1, 2

Step 3: Wound Care During Observation Period

• Daily wound inspection and dressing changes 2
• Monitor for signs of infection:
  • Progressive redness
  • Swelling
  • Purulent discharge
  • Increased pain
  • Fever 2

Step 4: Delayed Primary Closure Assessment (if chosen)

• Assess wound at 3-4 days for:
  • Absence of purulent drainage
  • Minimal erythema
  • Reduction in edema
  • Presence of early granulation tissue
  • No signs of necrotic tissue 2
• If these criteria are met, proceed with closure
• If infection is present, continue open management

Special Considerations

Antibiotics

• Not routinely indicated for all contaminated wounds
• Consider for:
  • Facial wounds being closed primarily
  • Signs of established infection
  • High-risk wounds (bites, punctures, crush injuries)
  • Immunocompromised patients 1, 5

Tetanus Prophylaxis

• Administer tetanus toxoid (0.5 mL intramuscular) if:
  • Last dose was >5 years ago for dirty/contaminated wounds
  • Last dose was >10 years ago for clean wounds
  • Vaccination status is unknown 1, 2

Dressings

• Maintain a moist wound environment with occlusive or semi-occlusive dressings 2, 6, 7
• Change dressings daily to evaluate for signs of infection

Pitfalls to Avoid

1. Premature closure: Closing contaminated wounds primarily (except face) significantly increases infection risk 1, 2
2. Inadequate debridement: Failure to remove all devitalized tissue can lead to infection even with delayed closure 2
3. Insufficient irrigation: Leaving contaminants in the wound increases infection risk 2
4. Delayed closure timing errors:
   • Too early (before bacterial load decreases) risks infection
   • Too late (after excessive granulation) worsens cosmetic outcome 2
5. Neglecting tetanus prophylaxis: Essential for contaminated wounds 1, 2

By following this approach, you can minimize infection risk while optimizing wound healing and cosmetic outcomes in contaminated wounds.