What is the recommended management for a cutaneous wound?

Management of Cutaneous Wounds

For general cutaneous wounds, irrigate thoroughly with tap water or sterile saline (both equally effective), avoid closing infected wounds, apply nonadherent dressings to open areas, and reserve antibiotics only for clinically infected wounds or high-risk situations.

Immediate Wound Assessment and Preparation

• Cleanse the wound thoroughly with copious irrigation using either running tap water or sterile normal saline—both are equally effective and superior to antiseptic solutions like povidone-iodine 1, 2, 3.
• Tap water does not increase infection risk compared to sterile saline and is a safe, cost-effective alternative in both hospital and community settings 3, 4.
• Remove superficial debris during irrigation, but perform deeper debridement cautiously to avoid enlarging the wound and impairing subsequent closure 1.
• Use an irrigation pressure of approximately 13 psi, which effectively cleanses wounds and reduces infection without causing tissue trauma 2.

Wound Closure Decisions

• Do not close infected wounds under any circumstances—closure dramatically increases the risk of abscess formation 1, 5.
• For clean, uninfected wounds presenting early (within 8 hours), wound margins may be approximated with Steri-Strips followed by delayed primary or secondary closure 1.
• Facial wounds are an exception: these can be closed primarily after meticulous irrigation and debridement, provided prophylactic antibiotics are administered, as cosmetic concerns outweigh infection risk in this location 1, 5.

Dressing Selection and Application

• Apply nonadherent dressings to denuded or open dermal areas such as Mepitel™ or Telfa™ to prevent adherence and trauma during dressing changes 1.
• Use a secondary foam or absorbent dressing (such as Exu-Dry™) to collect wound exudate 1.
• For wounds with intact epidermis or minimal denudation, apply a greasy emollient such as 50% white soft paraffin with 50% liquid paraffin over the entire area 1.
• Regularly cleanse wounds by gentle irrigation with warmed sterile water, saline, or dilute chlorhexidine (1:5000) 1.

Antimicrobial Management

• Administer systemic antibiotics only if there are clinical signs of infection (increasing erythema, purulent drainage, warmth, fever) 1.
• For wounds requiring prophylactic antibiotics (bite wounds, contaminated injuries, immunocompromised patients), use amoxicillin-clavulanate as first-line therapy to cover polymicrobial flora 1, 5.
• Apply topical antimicrobial agents (such as silver-containing products) only to sloughy or heavily contaminated areas, guided by local microbiological advice 1.
• Take bacterial and fungal cultures from wounds showing signs of infection before initiating systemic antibiotics 1.

Tetanus Prophylaxis

• Administer tetanus toxoid 0.5 mL intramuscularly if vaccination status is outdated (>10 years for clean wounds, >5 years for contaminated wounds) or unknown 1, 5.
• Tdap is preferred over Td if the patient has not previously received the acellular pertussis component 1.

Special Wound Types Requiring Modified Management

Bite Wounds (Animal or Human)

• Preemptive antibiotics are mandatory for patients who are immunocompromised, asplenic, have liver disease, have hand/face injuries, or have wounds potentially penetrating periosteum or joint capsules 1, 5.
• Amoxicillin-clavulanate 500 mg orally four times daily provides coverage against oral polymicrobial flora including Eikenella corrodens and anaerobes 1, 5.
• Clenched-fist injuries require urgent surgical evaluation due to high risk of joint penetration and septic arthritis 5.

Wounds with Extensive Tissue Loss

• If detached epidermis is present, it may be left in situ to act as a biological dressing after decompressing any blisters 1.
• Consider transfer to a specialized burn center for wounds with >30% body surface area involvement, clinical deterioration, or delayed healing 1.

Follow-up and Monitoring

• All outpatients with significant wounds require follow-up within 24 hours by phone or office visit to assess for signs of infection 1, 5.
• Elevate injured body parts, especially if swollen, to accelerate healing during the first few days after injury 1.
• Instruct patients to seek immediate care if redness, swelling, foul-smelling drainage, increased pain, or fever develops 5.

Critical Pitfalls to Avoid

• Never use antiseptic solutions like povidone-iodine for wound irrigation—they provide no benefit over water or saline and may impair healing 1, 2.
• Never routinely close contaminated or infected wounds—this dramatically increases infectious complications including abscess formation 1, 5.
• Never delay evaluation of hand wounds or wounds near joints—these require expert assessment for potential bone or joint penetration that could lead to osteomyelitis (requiring 4-6 weeks of antibiotics) or septic arthritis (requiring 3-4 weeks of antibiotics) 1, 5.
• Do not apply topical antibiotics to clean wounds—they offer no additional benefit and may promote resistance 5.