Initial Assessment

The initial evaluation before anesthesia should include a history of how the wound was sustained, factors that might impair healing, tetanus immunization history, and an assessment of peripheral neurovascular status.

For elective excisions, see Chapter 21, Incisions: Planning the Direction of the Incision, to plan the direction of the incision. If a traumatic laceration is to be repaired, see Table 22-1 for essentials of wound assessment. The clinician should consider the possibility of domestic violence in patients with traumatic wounds, especially if lacerations appear on the face or if multiple injuries of varying ages are noted.

TABLE 22-1 Essentials of Wound Assessment

In general, antibiotics are not needed for either wound or subacute bacterial endocarditis (SBE) prophylaxis for cutaneous procedures. For SBE prophylaxis guidelines, see Chapter 221, Antibiotic Prophylaxis. Consideration should be given to coverage for Staphylococcus aureus and methicillin-resistant S. aureus (MRSA) infection in several situations (Box 22-2).

The following are major goals for prescribing antibiotics before or after skin surgery:

The clinical decision-making process of whether or not to use antibiotics before or after skin surgery is complex. The physician must consider host factors, the anatomic location of the surgery, the sources that might contaminate the wound, and method of wound injury. Because this topic concerns wound repair after multiple types of trauma and elective procedures, the full complexity of the decision-making process is beyond the scope of this chapter. Box 22-2 lists the multiple factors to be considered when making a decision about antibiotic prophylaxis for skin procedures. See Chapter 222, Prevention and Treatment of Wound Infections.

The recommendations of the American Heart Association (AHA) for the prevention of bacterial endocarditis were last published in 2007. Endocarditis prophylaxis is not needed for incision or biopsy of surgically scrubbed skin. The 2007 guidelines state that antibiotic prophylaxis is recommended for procedures on infected skin and skin structures for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. For individuals at highest risk for endocarditis (see Chapter 221, Antibiotic Prophylaxis) who undergo a surgical procedure that involves infected skin or skin structures, it is reasonable that the therapeutic regimen administered for treatment of the infection contain an agent active against staphylococci and beta-hemolytic streptococci, such as an antistaphylococcal penicillin or a cephalosporin. Vancomycin or clindamycin may be administered to patients unable to tolerate a beta-lactam antibiotic or who are known or suspected to have an infection caused by MRSA.

Cummings and Del Beccaro (1995) performed a meta-analysis of randomized studies on the use of antibiotics to prevent infection of simple wounds. They concluded that there is no evidence in published trials that prophylactic antibiotics offer protection against infection of nonbite wounds in patients treated in emergency departments. Cummings (1994) also performed a meta-analysis of randomized trials for antibiotics to prevent infection in patients with dog-bite wounds and found that prophylactic antibiotics reduce the incidence of infection in these patients.

Antibiotics have a role in the treatment of many established skin infections. However, most skin abscesses are better treated with incision and drainage rather than with antibiotics. For skin procedures, there is not a consensus on whether to give an antibiotic and the appropriate timing for its administration. Recommendations for timing before the procedure vary from 1 hour (which is typical timing for bacterial endocarditis prophylaxis) to within 30 minutes of the procedure. Although a single second dose 6 hours later was the standard in the past, it is no longer currently recommended for bacterial endocarditis prophylaxis but may be advocated for further treatment of the infection.

Controversy exists over which bite injuries should be treated with prophylactic antibiotics. Cat- and dog-bite injuries carry the risk of infection with Pasteurella multocida, and human-bite injuries carry the risk of infection with Eikenella corrodens and S. aureus. Based on the microbiology of these wounds, amoxicillin/clavulanate provides good prophylactic coverage for the bacteria affecting most bite injuries. Alternatives include second-generation cephalosporins or clindamycin with a fluoroquinolone.

The best method for prevention of wound infections is to clean and irrigate traumatic wounds well, rather than relying on prophylactic antibiotics. The physician needs to weigh the benefits and the risks of antibiotic use based on the individual patient and the circumstances of the wound repair or skin surgery. The factors listed in Box 22-2 and the references at the end of this chapter should provide guidance for the physician making decisions about antibiotic prophylaxis for skin surgery.

Local Anesthesia

In traumatic wounds, neurovascular integrity should be assessed before administration of anesthesia. The wound should then be fully anesthetized to allow for painless examination of the tissue damage, thorough irrigation, and adequate closure. Many wounds can be adequately anesthetized with 1% or 2% lidocaine. Consider using lidocaine with epinephrine to provide increased hemostasis if there are no contraindications to epinephrine in the patient, the location of the wound, or the wound itself. (See Chapter 4, Local Anesthesia, and Chapter 8, Peripheral Nerve Blocks and Field Blocks.) Topical anesthetics are effective for wounds that do not involve mucosal surfaces. A combination of lidocaine, epinephrine, and tetracaine (LET) applied with a saturated cotton ball or as a gel formulation directly into the wound provides adequate anesthesia for many wounds.

Perform the following to minimize the pain of injecting local anesthetic:

Wound Preparation

After the initial assessment and administration of local or regional anesthetic, and antibiotics if indicated, wounds should be inspected thoroughly for foreign bodies, deep tissue layer damage, and injury to nerve, vessel, or tendon. A radiograph should be obtained to look for retained glass or metal in wounds sustained with broken glass or metal. Complex wounds or those in cosmetically important areas should be closed by a practitioner with the appropriate expertise.

Cleansing

After the wound is anesthetized, cleansing of a traumatic wound should be performed by irrigation with normal saline at approximately 15 psi of pressure. This can be accomplished by attaching an 18-gauge angiocatheter or a commercially available splash shield to a 30-mL syringe (see Fig. 22-1). At least 200 mL of irrigation is recommended. Moscati and associates (2007) performed a multicenter comparison of tap water versus sterile saline for wound irrigation showing equivalent rates of wound infection in immunocompetent patients. The tap water group irrigated their own wounds under the water tap for a minimum of 2 minutes after they had the wound anesthetized. Higher-risk wounds were excluded from the study, suggesting that tap water is a reasonable cleansing alternative only in low-risk lacerations. Chemical compounds such as hexachlorophene (pHisoHex), chlorhexidine gluconate (Hibiclens), or povidone–iodine (Betadine) should not be used inside wounds but may be applied to external, intact skin if desired. Greasy contaminants can be removed with any petroleum-based product, such as bacitracin ointment. To prevent a “road rash” tattoo, wrap petrolatum gauze around the fingers and wipe off the asphalt and other foreign material embedded in the skin after anesthesia.

For elective excisions, irrigation before closure is not generally needed. If there was a ruptured cyst or if the excisional area was open a considerable time, or if there was concern about contamination, irrigation with 10 mL of saline two or three times may be performed.

Débridement

After the cleansing process, wounds should be examined for devitalized tissue that needs removal or débridement. This débridement may convert a jagged, contaminated wound into a clean surgical one and can be accomplished with a scalpel or sharp tissue scissors (Fig. 22-2). Preserve as much tissue as possible in case future scar revision is necessary. After débridement, wound edges should be held together to see if they are under any tension. Wounds under significant tension are best repaired by a two-layer closure. In dirty wounds, however, this may increase the incidence of infection.

Figure 22-2 Débridement. A, Irregular jagged wound. B, Excise a jagged wound or crush injury to create a more readily reparable wound.

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