Wound Treatment and Management Principles
Wound management follows five fundamental principles: (1) thorough cleansing with sterile saline, (2) debridement of nonviable tissue, (3) maintaining a moist wound environment with appropriate dressings, (4) offloading pressure from the wound site, and (5) treating infection when present. 1
Initial Wound Assessment and Preparation
Before beginning treatment, ensure adequate lighting and patient analgesia, as inadequate pain control compromises your ability to perform thorough wound care 2. Measure and document wound dimensions (length, width, depth) to establish a baseline for healing assessment 2.
Critical Red Flags Requiring Immediate Specialist Referral:
- Pain disproportionate to injury severity near bone or joint suggests periosteal penetration and demands urgent evaluation 1, 2
- Exposed tendon or bone requires immediate hospital referral, even without infection signs 2
- Hand wounds warrant heightened concern as they are often more serious than wounds to fleshy body parts 1
Wound Cleansing Protocol
Cleanse all wounds with sterile normal saline only—do not use iodine-containing or antibiotic solutions for irrigation. 1, 2 Remove superficial debris during cleansing 1, 2. Despite traditional practice, hydrogen peroxide, Dakin's solution, and povidone-iodine are more tissue toxic than their common usage would indicate and should be avoided for routine wound cleaning 3, 4.
Debridement Strategy
Sharp debridement with scalpel is the preferred method for removing necrotic tissue, callus, and wound debris. 1 This converts chronic wounds to acute wounds and promotes healing 5. The scalpel, curette, and rongeur are much preferred to enzymatic agents when debridement is needed 3.
Perform debridement cautiously to avoid enlarging the wound and impairing skin closure 1, 2. If the wound is extensive or the patient finds the procedure too painful, conduct additional debriding sessions over several days rather than attempting complete debridement in one session 1. Ultrasonic and enzymatic debridement are acceptable alternatives when surgical debridement is not feasible 5.
Wound Dressing Selection
Select dressings based on wound characteristics to maintain a moist wound environment while controlling exudate. 1, 5
Dressing Algorithm by Wound Type:
- Dry or necrotic wounds: Hydrogels or continuously moistened saline gauze 1
- Exudative wounds: Alginates or foams 1
- Mixed presentation: Hydrocolloids for absorbing exudate and facilitating autolysis 1
- Minimal exudate: Films (occlusive or semiocclusive) for moistening 1
Do not use topical antimicrobials for treating clinically uninfected wounds—they provide no benefit and may be tissue toxic 1, 5.
Infection Management
Treat infection when present with systemic antibiotics, not topical antimicrobials 1, 5. Antimicrobial therapy is indicated for localized cellulitis, wounds with >1×10⁶ CFU, or difficult-to-eradicate bacteria (beta-hemolytic streptococci, pseudomonas, resistant staphylococcal species) 5.
For bite wounds specifically, use amoxicillin-clavulanate as first-line oral therapy 1. Avoid first-generation cephalosporins, penicillinase-resistant penicillins, macrolides, and clindamycin as they have poor activity against Pasteurella multocida 1.
Wound Closure Decisions
Infected wounds should never be closed. 1, 2 For clean wounds, suturing early (<8 hours after injury) is controversial—approximation of margins by Steri-Strips with delayed primary or secondary closure is the prudent approach 1, 2.
The exception is facial wounds, which can be closed primarily if seen by a plastic surgeon, provided there has been meticulous wound care, copious irrigation, and prophylactic antibiotics 1, 2.
Offloading and Elevation
For wounds on weight-bearing surfaces (particularly diabetic foot ulcers), offloading plantar ulcerations is essential 1. Elevate injured body parts, especially if swollen, using a sling for outpatients or tubular stockinet with IV pole for inpatients 1.
Advanced Wound Therapies
If a wound fails to show ≥50% reduction after 4 weeks of appropriate standard management, consider advanced wound therapies. 1, 5 These include:
- Negative pressure wound therapy for post-operative wounds 1, 5
- Hyperbaric oxygen therapy (may increase healing incidence and improve long-term outcomes) 1
- Bioengineered cellular therapies and acellular matrix tissues for chronic superficial ulcers 1, 5
- Growth factors (evidence for becaplermin remains to be confirmed) 1
Essential Adjunctive Measures
Ensure tetanus prophylaxis is current; if outdated or unknown, administer 0.5 mL tetanus toxoid intramuscularly 1, 2. For venous wounds specifically, compression therapy (20-40 mm Hg) combined with wound bed preparation heals ulcers more quickly than dressings or usual care without compression 5.
Common Pitfalls to Avoid
- Never apply topical antiseptics routinely—they are tissue toxic without proven benefit 1, 3, 4
- Never delay treatment of infection—foot infections can progress rapidly, increasing amputation and death risk 5
- Never perform full compression with ankle-brachial index <0.6 without revascularization—this indicates significant arterial disease 5
- Never assume minor wounds will heal without proper care—even small cuts and abrasions need appropriate management to prevent complications 6