What is the recommended initial assessment and management for an acute wound in an adult without known complicating conditions?

Initial Assessment and Management of Acute Wounds in Adults

For an acute wound in an adult without complicating conditions, immediately irrigate with copious sterile saline or clean tap water, assess for signs of infection or deep structure involvement, apply a non-adherent dressing that maintains a moist wound environment, and avoid routine antibiotic prophylaxis unless clear infection signs are present. 1, 2

Immediate Wound Assessment

Critical Parameters to Evaluate

• Measure wound dimensions: Document length, width, depth, and total area to establish baseline for monitoring healing progress 3
• Assess tissue appearance: Identify tissue types present (viable vs. necrotic), amount of each tissue type, and overall wound bed condition 3
• Evaluate for exposed structures: Look specifically for exposed bone, tendon, or joint capsule, as these require urgent surgical consultation 1, 2
• Check for infection signs: Temperature >38.5°C, heart rate >110 bpm, erythema extending >5 cm beyond wound margins, purulent discharge with foul odor, or pain disproportionate to wound appearance 1, 2
• Examine wound edges and surrounding skin: Assess for undermining, tunneling, and condition of periwound tissue 3

Common Pitfall to Avoid

Clear to yellowish serous drainage without foul odor is normal wound exudate and should not be mistaken for infection 2. Only purulent discharge with systemic signs warrants antibiotic therapy.

Initial Wound Cleansing

• Irrigate with copious sterile saline or clean tap water: No need for iodine-containing or antibiotic solutions, as these can impair healing 1, 2
• Remove superficial debris only: Avoid aggressive debridement initially unless clearly necrotic tissue is present 1
• Sharp debridement is preferred over hydrotherapy: When debridement is necessary, use scalpel, scissors, or tissue nippers rather than topical debriding agents 1

Wound Closure Decision

Do NOT Close If:

• Any signs of infection are present 1
• Wound is contaminated or has been open >8 hours (except facial wounds managed by specialists) 1
• Significant tissue loss or tension would result from closure 2

Closure Strategy:

• Approximate skin edges with Steri-Strips without tension rather than suturing 1, 2
• Plan for delayed primary closure (3-5 days) or healing by secondary intention depending on wound progression 2
• Facial wounds are an exception: Can be closed primarily by a plastic surgeon after meticulous irrigation and prophylactic antibiotics 1

Dressing Selection

• Apply non-adherent dressing that maintains moist wound environment: No specific dressing type has proven superiority; convenience and cost are appropriate considerations 1
• Ensure dressing allows daily inspection: This is critical for early detection of complications 1
• Avoid external cooling devices for prolonged periods: These can cause hypothermia and should not delay other interventions 1
• Change dressings every 5-7 days if no complications arise 2

Antibiotic Decision Algorithm

NO Antibiotics Needed If:

• Erythema <5 cm from wound margins 1
• Temperature <38.5°C 1
• WBC count <12,000 cells/µL 1
• Heart rate <100 beats/minute 1

Short Course (24-48 hours) Antibiotics If:

• Temperature >38.5°C OR heart rate >110 bpm 1, 2
• Erythema extending >5 cm beyond wound margins 1, 2

Broad Empiric Antibiotics If:

• Signs of systemic toxicity or suspicion of necrotizing infection: Use vancomycin or linezolid PLUS piperacillin-tazobactam or carbapenem 1

Routine antibiotic prophylaxis should NOT be administered for clean acute wounds 1. Studies of subcutaneous abscesses found little to no benefit for antibiotics when combined with drainage 1.

Adjunctive Measures

• Elevate injured body part if swollen: This accelerates healing, especially during first few days 1
• Off-load pressure from wounds on weight-bearing surfaces: Critical for healing, but choose devices that permit easy inspection 1
• Ensure tetanus prophylaxis is current: Administer 0.5 mL tetanus toxoid intramuscularly if outdated or unknown 1

Follow-Up Protocol

• Examine within 24 hours: Either by phone or office visit to assess for infection signs 1, 2
• Monitor regularly until healing: Reassess all wound parameters at each dressing change 3
• If infection progresses despite appropriate therapy: Consider hospitalization 1

Critical Pitfalls to Avoid

• Do not suture infected wounds or wounds that have already dehisced: This increases infection risk and causes further tissue trauma 1, 2
• Do not use first-generation cephalosporins, macrolides, or clindamycin alone for bite wounds: These have poor activity against common pathogens like Pasteurella multocida 1
• Do not delay surgical consultation for aggressive infections: Necrotizing fasciitis or gas gangrene requires prompt surgical intervention 1
• Do not use topical antibiotics or antimicrobial dressings routinely: Reserve these for clearly infected wounds 1, 2