What is the recommended treatment for a minor to moderate skin abrasion in a patient with no known impaired renal function, no history of allergies, and an unknown tetanus vaccination status?

Treatment of Minor to Moderate Skin Abrasions

For a minor to moderate skin abrasion, thoroughly irrigate the wound with copious amounts of clean water (tap water or sterile saline), apply antibiotic ointment if no allergies are present, cover with an occlusive dressing, and administer tetanus toxoid (Tdap preferred) since vaccination status is unknown. 1, 2

Immediate Wound Care

Irrigation and Cleansing

• Irrigate the abrasion thoroughly with a large volume of warm or room-temperature potable tap water or sterile saline until all foreign matter is removed 1
• Cold water is equally effective but less comfortable for the patient 1
• There is no evidence that antiseptic irrigation solutions are superior to sterile saline or tap water 2
• If running water is unavailable, use any available source of clean water 1
• Superficial debris should be removed during irrigation 1

Topical Treatment

• Apply antibiotic ointment or cream to the abraded area 1
• This should only be applied if the wound is an abrasion or superficial injury and the patient has no known allergies to the antibiotic 1
• Wounds covered with antibiotic ointment or cream heal better with less infection compared to uncovered wounds 1

Wound Coverage

• Cover the wound with a clean occlusive dressing 1
• Occlusion is key to preventing contamination and promoting optimal healing 2, 3
• The dressing creates an environment that accelerates healing 1

Tetanus Prophylaxis - Critical Priority

Since tetanus vaccination status is unknown, tetanus toxoid must be administered as soon as possible 1, 2

Specific Recommendations:

• Administer Tdap (tetanus, diphtheria, and pertussis) vaccine if not previously given 1
• If Tdap is unavailable, administer Td (tetanus and diphtheria) vaccine 1
• The standard dose is 0.5 mL intramuscularly 1
• For patients with unknown or uncertain tetanus immunization history, consider them as having had no previous doses 1
• Abrasions are considered "dirty wounds" - tetanus prophylaxis is indicated if vaccination status is unknown or if >5 years have elapsed since the last dose 1

Important Caveat:

• If the patient has not completed a primary tetanus vaccination series (3 doses), they may require both tetanus toxoid vaccine AND tetanus immune globulin (TIG) 250 units IM at a separate anatomic site 1
• However, for a simple abrasion in a patient with unknown status, starting with tetanus toxoid alone is reasonable 1

Adjunctive Measures

Elevation

• Elevate the injured body part, especially if swollen, during the first few days after injury 1
• This can be accomplished passively using a sling for outpatients 1
• Elevation accelerates healing 1

Follow-Up

• Patients should be followed up within 24 hours, either by phone or office visit 1
• Provide written discharge instructions regarding wound care and the need to complete any vaccination series 1

What NOT to Do

Avoid These Interventions:

• Do not use pressure points or elevation as primary methods to control bleeding - these are not recommended as they are unproven and may compromise direct pressure if bleeding is present 1
• Do not apply ice directly to the wound 1
• Do not use iodine- or antibiotic-containing irrigation solutions - plain water or saline is sufficient 1
• Do not perform deep debridement on simple abrasions - this may enlarge the wound unnecessarily 1

Antibiotic Prophylaxis

Prophylactic systemic antibiotics are NOT indicated for simple, clean abrasions 2

• There is no evidence that prophylactic antibiotics improve outcomes for most simple wounds 2
• Topical antibiotic ointment is sufficient for infection prevention in uncomplicated abrasions 1
• Systemic antibiotics should be reserved for wounds showing signs of infection (erythema >5 cm, fever >38.5°C, elevated WBC) 1

When to Refer or Escalate Care

Red Flags Requiring Further Evaluation:

• Wounds covering large areas of the body 2
• Wounds involving the face, joints, bone, tendons, or nerves 2
• Signs of infection developing (increasing pain, erythema, purulent drainage, fever) 1
• Pain disproportionate to injury severity, suggesting deeper tissue involvement 1

Common Pitfalls to Avoid

• Failing to administer tetanus prophylaxis when vaccination status is unknown - this is a critical error that can lead to preventable tetanus infection, a potentially fatal disease 1
• Assuming tap water is inadequate for irrigation - it is equally effective as sterile saline 1, 2
• Over-treating with systemic antibiotics when topical treatment is sufficient 2
• Neglecting to elevate the injured area, which delays healing 1